Psychotherapy Process Research Research Articles

Teaching students to identify and address significant critical moments in cross-cultural social work practice

ABSTRACT Critical social work practice should transcend across micro, mezzo, and macro levels, and it is a social work educator’s responsibility to foster skills that are contextualized and connected to social justice and anti-oppressive frameworks. Despite the importance of addressing and integrating systemic oppression in cross-cultural social work practice, students struggle with being able to translate their knowing into doing. Using a video case of a client named Glen who is receiving services in an outpatient addiction counseling program, we discuss how to incorporate a critical, systemic, and structural lens in social work mental health practice. Psychotherapy process research cautions against weighing an entire session equally and underlines the importance of examining critical moments within the session. Guided by a psychotherapy process research approach, we illustrate how we train students to identify significant in-session moments and encourage students to brainstorm and practice in-session social work tasks that integrate a structural lens with clinical interventions. This teaching approach also illustrates how to translate critical scholarship and approaches into micro-level teachable moments in classroom to guide students’ cross-cultural practice. The pedagogical approach using a micro-analysis of in-session social work tasks heightens students’ awareness and competence in how to intervene with culturally diverse clients.

Psychotherapy process research: Identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness

ABSTRACT This paper provides an overview of my research programme for the past 37 years. The focus of my work has been on identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness. Two foci will be reviewed, first, my research on client and therapist interpersonal process and second, productive processing in psychotherapy in three different therapeutic approaches including EFT, CBT and CCT. Given that many competing theoretical perspectives are effective, I was curious about change processes that are common and unique to each. In my work, I employed a variety of research methodologies drawing on frameworks with alternative epistemological and ontological assumptions to capture specific in-session change processes in an attempt to reveal the richness and complexity of the phenomena being studied and illuminate the process of change.

Emotional change in its "natural habitat": Measuring everyday emotion regulation with passive and active ambulatory assessment methods.

Ambulatory assessment methods have made it possible to study psychological phenomena in real-time, with translational potential for psychotherapy process research. This article uses case example data to demonstrate applications of ambulatory assessment to measuring emotion regulation, a process with relevance across diagnoses and treatment modalities that may be particularly important to measure in situ. Two methods are reviewed: Ecological Momentary Assessment (EMA), which enables self-reported momentary assessments as people go about their days, and the Electronically Activated Recorder (EAR), an unobtrusive naturalistic observation methodology that collects short audio recordings from participants' moment-to-moment environments, capturing an acoustic diary of their social interactions, daily behaviors, and natural daily language use. Using case example data from research applying EMA and EAR methods in the context of adolescent self-injurious thoughts and behaviors, we illustrate how EMA can be used to measure emotion regulation over time and across contexts, and how EAR can assess the behaviors and social-environmental factors that interact with emotion regulation in clinically important ways. We suggest applications of this measurement approach for investigations of clients' emotional change over the course of psychotherapy, as well as potential clinical applications of these methods.

Lessons from ten years of psychotherapy process research

Objective: The aim of this review is to systematize and interpret results produced over one decade of Psychotherapy Process Research (2009–2019) in eight journals. Method: It is a Mixed Studies Review of quantitative as well as qualitative primary studies. The analysis of the results of these studies included a descriptive quantitative part and a qualitative part that followed the logic of Qualitative Meta Analysis, categorizing the main results of both types of studies in a bottom-up procedure that generates specific content categories that are synthesized in further steps of a higher level of abstraction, leading to an “interpretive synthesis” presented in a narrative way. Results: The review shows that psychotherapy process research uses a variety of qualitative and quantitative methods, often creating new procedures. Furthermore, the review indicates that the most commonly assessed macroprocess variables are ongoing change, therapeutic relationship (predominantly therapeutic alliance), and therapeutic intervention; while the most extensively studied microprocess variables are change events, difficult episodes (mainly ruptures), and therapeutic intervention. Macrolevel results reveal that the main contents of ongoing change are the building of new meanings and progressive psychological integration; underscore the association of the therapeutic alliance with ongoing change and outcome; and show the complexity of associating intervention with outcome, because different phases of therapy (and problems) need different assessments. Microlevel results indicate that change events impact on ongoing change and outcome; that for ruptures the key fact is their repair; and that therapist communication has an immediate influence on patient communication. Conclusion: Our knowledge regarding relevant aspects of psychotherapy is very fragmented; robust and replicated results are still scarce. Only a few variables have been found to consistently predict outcome across most therapies. Only in the field of alliance research it has been possible to perform meta-analyses that clearly demonstrate the impact of this factor on final outcomes. Despite these limitations, psychotherapy process research is a powerful tool for uncovering change mechanisms and is at present widely implemented. Our conclusion is that, in order to generate useful future knowledge, change mechanisms need to be linked to ongoing change; this, in turn, requires models of change, hopefully of a transtheoretical nature.

Changes in group counseling engagement and conflict and growth in emotional cultivation for children and adolescents.

Group climate is an important factor in group counseling and psychotherapy process and outcome research. The current investigation examined group climate changes (from early to late sessions) at the within-group (i.e., group members) and between-group (i.e., group-as-a-whole) levels in predicting changes in group members' emotional cultivation in group counseling. A total of 236 Taiwanese children and adolescents across 41 groups participated in this study. Members' ratings of group climate (i.e., engagement and conflict) were partitioned into within-group and between-group components, and polynomial regression with response surface analysis was used to examine the association between changes in group engagement and conflict (at the member- and group-level) from early to late group sessions on changes in emotional cultivation. Results supported the theoretical hypothesis that when a group-as-a-whole reported increasing engagement from early to late group sessions, relative to other groups (i.e., between-group effect), members of that group experienced greater growth in emotional cultivation. Results also indicated that group members reported greater growth in emotional cultivation when there was consistent and high engagement or consistent and low conflict from early to late group sessions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

In defence of loose ends: Psychotherapy process research in the real world

Understanding what transpires in therapeutic conversations is as complex as the humans who are engaged in them. Inspired by the natural sciences, mainstream research in psychotherapy has taken up a positivist epistemology and strives for quantification and verification to produce evidence of the effectiveness of an approach. This paper explores an alternative foundation for therapeutic practices which has implications for how we do research. First, we present some ideas from process philosophy and dialogical perspectives.. In particular we return to the ideas of Henri Bergson who understood change as consisting of interpenetrated continuous and shifting states. In a next step we briefly look into how such ideas have influenced what is referred to as dialogical practices. Such dialogical practices operate through facilitating polyphonic, diverse perspectives that may mediate change in and through an intersubjective process of becoming. Based on this we take another step and make some suggestions for how we may develop research that enables ways of exploring therapeutic conversations as a multi-voiced, interactional and unfinalized process. We offer by way of example a method by which we attempt to integrate a linguistic theory (Systemic functional linguistics) with the dialogical framework and the ideas of Bergson. This paper considers how process philosophy may offer an alternative to the seeking of certainty that occurs in both psychotherapy research and practice, and ideas for making space for the ‘loose ends’ of the inconsistent and the unknown.

How expectations and therapeutic style influence counselling outcome

AbstractObjectiveWith a lack of experimental designs in psychotherapy/counselling process research, evidence is limited regarding which therapeutic style is helpful for which patient and the role of expectations. Therefore, the aim of this experimental study was to manipulate the therapeutic style and clients' expectations towards psychological counselling and investigate their effects on counselling outcome.MethodEighty healthy participants (74% female, Mage = 31.2 years, SDage = 12.21) received a single counselling session focussing on interpersonal conflicts. We defined two therapeutic styles (relationship‐focussed vs. problem‐focussed) based on the interpersonal circumplex, and participants were led to believe they would receive one of the two styles. In the actual counselling session, they received either the expected or the contrary, resulting in a 2 x 2 design. Primary outcome rated by participants was subjective impairment caused by the conflict 2 weeks after the session; secondary outcomes were satisfaction with the session and perceived working alliance.ResultsThe successful implementation of the proposed therapeutic styles was confirmed by adherence ratings (U = 25.50, p < 0.001) and ratings of counsellors’ behaviour in the circumplex model (p < 0.001) for the friendly and hostile dimensions. Impairment was significantly reduced 2 weeks after the counselling session, but this effect was dependent on neither the therapeutic style, clients' expectations, nor their interaction.DiscussionThe study provides the first evidence that a single counselling session appears to be effective in alleviating impairment caused by an interpersonal conflict, independent of the counselling style and client expectations. The novel experimental design provides a basis for further process research in psychological counselling and psychotherapy.

Introduction and evaluation of a therapeutic adherence and competence scale for grief-focused cognitive behavioural therapy

ABSTRACT Background: There is no therapeutic competence and adherence scale for grief-focused cognitive behavioural therapy (grief-focused CBT). However, given the growing body of evidence for the efficacy of grief-focused CBT, such a scale is needed both to ensure the internal validity of clinical trials and to facilitate psychotherapy process research. Objective: To develop and undertake a psychometric evaluation of a therapeutic adherence and competence scale for grief-focused CBT. Method: The scale was developed in two steps. (I) Five experts on the treatment of prolonged grief disorder provided feedback on the relevance and appropriateness of the items. The scale was revised to reflect their feedback. The final therapeutic adherence and competence scale for grief (TACs-G) consisted of 15 adherence and 16 competence items. (II) Psychometric evaluation of the TACs-G was based on the rating of 48 randomly selected PG-CBT sessions by two independent raters. The videos were recorded in the context of a randomized controlled trial (RCT; DRKS00012317.) ICC was used to calculate inter-rater reliability and TACs-G stability over time (re-evaluation of 10 sessions after 12 months). Results: The five experts confirmed the relevance and appropriateness of the items. Interrater reliability was found to be high for the total adherence and competence scores (ICC = 0.889 and 0.782, respectively) and moderate to excellent for individual items (ICC = 0.509–1.00). The TACs-G stability over time was found to be strong for both adherence (ICC = 0.970) and competence total scores (ICC = 0.965). Conclusions: The TACs-G for CBT is a reliable instrument that can be used not only to ensure internal validity but is also suited for psychotherapy process studies. Additionally, it provides a valuable database for targeted feedback in training settings. HIGHLIGHTS This is the first study to report on the development and psychometrical evaluation of a grief-focused adherence and competence scale. Although an increasing number of clinical trials do report the efficacy of grief-focused cognitive–behavioural therapy, none of these studies used a standardized adherence and competence scale to control internal validity. In the present study, we introduced a therapeutic adherence and competence scale for grief (TACs-G) that can be applied efficiently across different research settings (e.g. manipulation check, dissemination), and report results of good to excellent psychometric properties. The scale itself could prove useful beyond the research setting as it could possibly serve as a basis for feedback in training settings.

Facilitative interpersonal skills are relevant in child therapy too, so why don't we measure them?

One of the consistent findings from psychotherapy process research has been the impact of therapist effects on patient change and the therapeutic alliance. The Facilitative Interpersonal Skills (FIS) paradigm is a task in which participants respond to standardized videos of actors playing patients in interpersonally challenging moments as if they were the therapist, which was designed to assess therapist effects. Participants’ video recorded responses are coded for eight skills: verbal fluency, emotional expressiveness, warmth/acceptance/understanding, empathy, persuasiveness, hope/positive expectations, alliance-bond capacity, and rupture-repair responsiveness. Performance-based procedures like the FIS minimize self-report bias and systematically control for client-related variability while maintaining strong clinical relevance. Research has shown that therapist FIS predicts the quality of the therapeutic alliance and outcome in adult psychotherapy. This paper describes the development and first adaptation of the FIS task using child and adolescent patients as the stimuli, and reports findings from a pilot study testing the reliability. The FIS-Child (FIS-C) task was administered to 10 therapists with a range of clinical backgrounds. Participants also completed the original FIS task and self-report measures of their empathy, social skills, and playfulness. Adequate interrater reliability was achieved on the FIS-C. There were no significant differences between participants’ ratings on the FIS-C compared to the original FIS, although there were minor differences in the correlations between the FISC and self-report measures compared to the original FIS. Findings support moving forward with utilizing the FIS-C to empirically study therapist effects that may be common factors across treatment models.

Writing evocative case studies: applying autoethnography as a research methodology for the psychotherapist

This is an introduction to the application of autoethnography, a qualitative research method, an aesthetic inquiry into the psychotherapy process. The method engages the practitioner as researcherautoethnographer who enters a field, which is their client’s therapy process. The aim is to derive insights and deepen the understanding of process, theory and diagnostics from psychotherapy sessions in practice. The therapist creates a reflexive account of their experiences, recording this in their session notes, which are also the field notes and the data. As an autoethnographer, the therapist begins therefrom a process of creative writing. The writing process is reflexive, and aesthetic. Integral to the research method, the act of writing forms a hermeneutic circle where new insights of the phenomenon of therapy happen for the researcher. The writing is created as an art form, usually a story or poetry. The result of this method is a written, evocative, aesthetic representation of the therapy process, based on the phenomenological experience of the practitioner. Demonstrating this method, a single case study of an online Gestalt therapy session of a male client diagnosed with depression and borderline personality disorder is featured in this article. The outcome of this form of aesthetic inquiry is the embodiment of psychotherapy theory through the aesthetic sensibility of the therapist-researcher. Keywords autoethnography, psychotherapy case studies, psychotherapy process research, Gestalt therapy, aesthetic inquiry

Child and Adolescent Psychodynamic Therapy: Using Q-Methodology in Process Research

ABSTRACT Psychotherapy for children and adolescents has been shown to be generally effective in treating a wide variety of psychological problems. In spite of this success, the field has been slow to identify the key therapeutic processes responsible for changes in psychiatric symptoms, emotional well-being, social relationships, and school functioning observed across theoretically different treatment models. The child and adolescent psychodynamic psychotherapy literature lags far behind the adult literature in assessing the change processes associated with the successful treatment of children and adolescents. This article reviews the rapidly growing literature engaged in the pursuit of articulating the change processes associated with successful treatment outcomes for children and adolescents. Two classes of change processes are reviewed: interaction structures (i.e., patterns of reciprocal therapist-patient interaction) and adherence to “brand-name” treatment models (e.g., child psychodynamic therapy). Researchers have used children’s psychiatric diagnoses most commonly as moderators of significant process-outcome associations. This article will explore the contributions of the Child Psychotherapy Q-Set (CPQ) and Adolescent Psychotherapy Q-Set (APQ) to this field of study, while also reviewing some of the data analytic strategies used. Finally, an outline of the future directions of child and adolescent psychodynamic psychotherapy process research using the CPQ and APQ is suggested.

Beyond the outcomes: generic change indicators in a video-feedback intervention with a depressed mother and her baby: a single case study.

Child and dyadic psychotherapy have been scarcely investigated from the psychotherapy process research perspective. Thus, content and mechanisms related to therapeutic change have been overlooked by research. This study aimed at testing the applicability of the generic change indicators (GCI) model to identify moments of change in the parent during dyadic interventions, as well as to explore, describe and illustrate the therapeutic process through a brief mentalization-informed intervention with a depressive mother and her baby, using video-feedback as its main strategy, which has ample evidence about its effectiveness. We conducted a single case qualitative study using the GCI model. The mother’s ongoing change was determined by identifying episodes of change (EC) and moments of change (MC). Each MC was then labelled with one of the 19 GCIs. GCIs were observed from the intervention’s start. GCI’s hierarchical levels were increasing over the intervention, in association with the video-feedback situation. Our findings suggest that the GCI model is feasible to observe and understand dyadic interventions, contributing to the growing body of evidence supporting psychotherapists’ training and supervision.

More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research.

While the evidence on the effectiveness of different psychotherapies is often strong, it is not settled whereby and how these therapies work. Knowledge on the causal factors and change mechanisms is of high clinical and public relevance, as it contributes to the empirically informed advancement of psychotherapeutic interventions. Here, digitalized research approaches might possess the potential to generate new insights into human behavior change, contributing to augmented interventions and mental healthcare practices with better treatment outcomes. In this perspective article, we describe recent findings of research into change mechanisms that were only feasible with digital tools and outline important future directions for this rather novel branch of research. Furthermore, we indicate several challenges and pitfalls that are to be solved, in order to advance digitalized psychotherapy process research, both methodologically and technologically.

Can we learn on Psychotherapeutic Process Dimensions with Single Case Study?

Relational psychoanalysis states that an adequate management of the intersubjective processes displayed in psychotherapy are essential to promote effective change. The analysis about some variables of the therapist and patient and the complex and co-determined interaction between them, give us new perspectives on the therapeutic process. This analysis leads us to question some topics and consider from a new view the therapist's functions and the patient's roles within the therapeutic process. A group of researchers in Spain, Argentine, Mexico and Germany have worked along a decade (1997-2008) in the Salamanca-Barcelona-Madrid Project on Psychotherapy Process Research. This project, an study conducting single case research (´The Publicist´ case), along the main phases of complete treatment (up to 200 recorded sessions), have given us the opportunity to adquire a better knowledge on therapeutic process, through the content analysis of sessions and with qualitative data using a wide variety of procedures. In this paper we are presenting relevant results concerning some inferences on therapeutic process along the whole treatment and their phases. Crossing all the studied dimensions, we propose a comprehensive model of change observed in the case object of study, considering all the approaches, both from quantitative and qualitative methods and process dimensions, both the contributions of the therapist and the patient to psychotherapeutic process. Results are discussed in the light of recent perspectives on active use of counter-transference as a therapist’s tool to improve the psychoanalytic psychotherapy process, controlling negative aspects of countertransference collusions.

What Research Evidence Is Valid for Psychotherapy Research?

Evidence-Based Medicine (EBM) have contributed to improved clinical practice with increased use of effective and life-saving treatments for severe diseases. However, the EBM model is less suitable for psychotherapy research than for pharmacological research and somatic medicine. The randomized controlled trial (RCT) design is an example of experimental methodology, which inevitably has more imperfections in psychotherapy research because psychotherapy RCTs cannot use double-blinding and the treatments tested are composite treatment packages. Long-term psychotherapy for severe and complex mental disorders is especially difficult to study with an RCT design. During the last decades, advanced analytic methods have been developed in psychotherapy process research, which enables investigation of causal connections regarding change mechanisms in psychotherapy. Therefore, we propose that the top of the research evidence hierarchy for psychotherapy should encompass: (1) RCT for circumscribed disorders, (2) cohort studies for complex disorders, and (3) advanced process studies for change mechanisms.

Η κατασκευή της Κλίμακας Ισχύος του Συναισθήματος και οι εφαρμογές της στην έρευνα της ψυχοθεραπευτικής διαδικασίας

Η ΠΕΡΙΛΗΨΗ ΒΡΙΣΚΕΤΑΙ ΜΕΣΑ ΣΤΟ ΑΡΧΕΙΟ PDF

Seeing the Situational Gestalt - Movement in Therapeutic Spaces

Summary This paper starts with a short review of recent developments in psychotherapy process research and analyzes that a medical, or better, technical approach in process research – using words such as ‘intervention’, ‘effect’ and ‘outcome’ – is gradually acknowledged as only one side of psychotherapy; the other, more human or ‘humanistic’ side, is ‘conversation’, described by prominent authors as ‘low technology’. Conversation analysis cannot study psychotherapy as a whole. Sessions are subdivided into ‘situations’. What are situations? I make a proposal to answer this question by three components: open up, select and control options. Then, 11 transcribed extracts from psychoanalytical therapy sessions are used to describe three types of situations and the special kind of requirements they demand from a therapist. Obviously, such situations appear during a session, they can be handled if therapists are sensitized for certain difficulties to arise. Shift-of-situation and double meaning are new observations in this approach to define the situational gestalt and train ‘seeing’ it.

Supervised Speaker Diarization Using Random Forests: A Tool for Psychotherapy Process Research.

Speaker diarization is the practice of determining who speaks when in audio recordings. Psychotherapy research often relies on labor intensive manual diarization. Unsupervised methods are available but yield higher error rates. We present a method for supervised speaker diarization based on random forests. It can be considered a compromise between commonly used labor-intensive manual coding and fully automated procedures. The method is validated using the EMRAI synthetic speech corpus and is made publicly available. It yields low diarization error rates (M: 5.61%, STD: 2.19). Supervised speaker diarization is a promising method for psychotherapy research and similar fields.

Feasibility and acceptability of a novel tool for the study of interpersonal processes in psychotherapy.

Psychotherapy process research methods often require extensive time and resources. Technology innovations, such as wearable sensors, have the potential to increase the efficiency of process data collection and processing. One such tool is the Sociometric Badge (SB), which is a portable, palm-sized device that can simultaneously record raw audio and data on social signals (e.g., speech patterns, body movement) in real-time and in varied contexts. In addition to describing the nature and implications of wearable sensing devices for psychotherapy research, this article reports results from a pilot study that examined the feasibility and acceptance of these assessment devices in comparison with traditional audio recording equipment. Undergraduate students (N = 306; Mage = 19.16 years, SD = 1.44; 50.3% female) were randomly placed into 153 dyads to mimic a psychotherapy dyad. Each dyad was randomly assigned to either a SB condition (n = 75 dyads) or a standard recording device condition (n = 78 dyads), and engaged in a conversation task. Participants completed self-report items assessing perceived relationship quality and experience with the respective recording device. Between-condition tests showed that perceived relationship quality did not differ between conditions. Participants in the audio recorder (vs. SB) condition reported more awareness of the device in the room. These findings reveal comparable acceptability and feasibility of SBs to traditional audio recorders in a simulated dyad, suggesting that wearable sensing devices may be suitable for research and practice in routine psychotherapy contexts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pay no attention to the man behind the curtain: The overlooked issue of rater selection in psychotherapy observer ratings

Objective: Psychotherapy process research relies heavily upon trained raters to identify and code therapist and client behaviors. Raters are often selected out of convenience or availability with little research to inform what qualities are desirable for this role. In this study, we evaluated several rater characteristics as potential predictors of raters’ performance. Method: We provided training to 39 undergraduate students to serve as raters in a psychotherapy process study. We assessed baseline characteristics, personality characteristics, executive functioning, and interviewers’ assessment of students’ rating potential as predictors of rater agreement with gold standard ratings (i.e., consensus judgements from a panel of CBT-trained clinicians). We also assessed these variables as predictors of the risk of raters dropping out prior to completing assigned ratings. Results: Higher conscientiousness, higher neuroticism, and a lower year in college predicted greater agreement with the gold standard ratings. Lower year in college also predicted lower risk of dropout. Conclusion: These findings provide empirical support for key characteristics as predictors of rater performance. Such evidence raises the possibility of using these characteristics to select raters and thereby enhance the psychometric properties of psychotherapy ratings.