Psychotherapy practice and research. Repairing a strained alliance

Life Is About Change: A Professional Memoir

Receiving my doctorate in 1961 just as John F. Kennedy was inaugurated president of the United States, I was inspired by his sentiment that any person can make a difference, and every person should try. In this memoir I review my professional journey of trying to make a difference in researching, teaching, supervising, and practicing clinical psychology and psychotherapy. I began my career by working on an evidence base for projective techniques. Upon joining the Stony Brook faculty, I shifted my efforts to research on and practice of behavior therapy, and then to the incorporation of cognition in developing cognitive behavioral therapy. Further work on integration consisted of closing the gap between research and practice, lowering the barriers that existed across schools of therapy, and incorporating lesbian, gay, bisexual, and transgender issues into mainstream psychology.

The Importance of Conducting Practice-oriented Research with Underserved Populations

There has been a growing emphasis on dissemination of empirically supported treatments. Dissemination, however, should not be restricted to treatment. It can and, in the spirit of the scientific-practitioner model, should also involve research. Because it focuses on the investigation of clinical routine as it takes place in local settings and because it can involve the collaboration of several stakeholders, practice-oriented research (POR) can be viewed as an optimal research method to be disseminated. POR has the potential of addressing particularly relevant gaps of knowledge and action when implemented in regions of the world that have limited resources for or experiences with empirical research, and/or in clinical settings that are serving clinical populations who are not typically receiving optimal mental care services - specifically, individuals in rural and inner cities that have limited economic and social resources. The establishment and maintenance of POR in such regions and/or settings, however, come with specific obstacles and challenges. Integrating the experiences acquired from research conducted in various continents (Africa, Europe, Latin America, and North America), the goal of this paper is to describe some of these challenges, strategies that have been implemented to address them, as well as new possible directions to facilitate the creation and growth of POR. It also describes how these challenges and ways to deal with them can provide helpful lessons for already existing POR infrastructures.

Psychotherapy outcome research: Implications of a new clinical taxonomy

Since the publication of DSM-III in 1980, the scientist-practitioner gap in clinical psychology has expanded, as almost all outcome research in clinical psychology has been on diagnosed mental disorders within a medical model using drug trial methodologies, whereas most practising clinicians undertake functional analyses and case formulations of clinical psychological problems (CPPs) and then apply tailored interventions within an ongoing hypothesis-testing methodology. But comparatively reliable assessment and generalizable conclusions in psychotherapy outcome research require a comprehensive theory-derived conception or operational definition of 'CPPs', standardized functional analyses, and a taxonomy of CPPs comparable to DSM's listings of mental disorders. An alternative conception and taxonomy of CPPs have recently been proposed, offering improvements in the reliability and generalizability of case formulation-based psychotherapy outcome research. It conceives of CPPs as instances of the formation and operation of self-sustaining problem-maintaining circles (PMCs) of psychological-level causal elements-that is, at the level of cognitions, behaviours, emotions, and events or situations (stimuli). The paper describes this new conception of CPPs, a subsequent nascent taxonomy of evidence-based PMCs which standardizes the underlying mechanisms that maintain CPPs, and ensuing benefits to research (as well as to practice) in clinical psychology. These benefits include being able to encompass all treatment-worthy CPPs, not just diagnosable mental disorders; to assess theory-derived intervention strategies, not just arbitrary therapy bundles; and to directly feed back into psychological theories, not just expand an atheoretical list of patented "evidence supported therapies."

The relationship between depressive symptoms, general psychopathology, and well-being in patients with major depressive disorder

OBJECTIVE

In mental health care, treatment effects are commonly monitored by symptom severity measures. This study aimed to investigate the relationship between symptom severity and well-being in the treatment of patients with major depressive disorder (MDD).

METHODS

Adult MDD outpatients (n = 77) were administered the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR), the Outcome Questionnaire (OQ-45), and the Mental Health Continuum-Short Form (MHC-SF) before treatment and 6 months later.

RESULTS

Symptom severity correlated moderately with well-being at baseline and strongly at follow-up. Reliable change index scores showed improvement on the QIDS-SR, OQ-45, and MHC-SF in 65%, 59%, and 40%, respectively. A quarter of patients improved in symptom severity but not well-being (Inventory of Depressive Symptomatology-Self-Report [IDS-SR]: 25%; OQ-45: 24%).

CONCLUSION

Findings suggest that symptom severity and subjective well-being are related, but distinct concepts. Several reasons for the stronger improvements in symptoms than in well-being are discussed.

Emotion Regulation Focused Family Therapy With Contemporary Families Affected by Information and Communication Technologies

In the contemporary world, new information and communication technologies (ICTs) have revolutionized family relationships and organization. Mobile phones, tablets, and computers are entrenched in everyday family life. Therefore, families face new challenges with problematic internet use, blurring boundaries between the outside world and the domestic sphere. Sometimes these changes in living together lead to suffering. How do therapists respond to these new challenges faced by contemporary families? Considering the emotion regulation strategies underlying the problematic use of technology, we develop an Emotion Regulation Focused Family Therapy. Within the Change Process Research paradigm, which aims to explain how psychotherapy produces change, we examine this innovative therapeutic approach in an exploratory process in order to refine our own practice. We conducted a qualitative research for five families in family therapy under natural clinical conditions to identify the therapist's interventions and the family configurations. The core theme was therapist interventions. The results identified 12 subcategories under this category. We built an emotion regulation focused model with 12 steps from these subcategories. Each of the interventions is illustrated with some excerpts from the sessions. Clinical considerations, methodological issues limiting the current body of work, and recommendations for future research are discussed.

Introducing SYPRENE: An International Practice Research Network for Strategic and Systemic Therapists and Researchers

SYPRENE, a new international Systemic Practice Research Network (PRN), has been established to fill the gap in practice-based research on the effectiveness and efficiency of strategic therapies. This article presents the rationale for the creation of SYPRENE and describes data collection methods, and the encoding system implemented within this PRN. More developments are expected in the recruitment of practitioners, the types of data collected, findings, and the implementation of SYPRENE in supervision, trainings, and professional schools.

Control Conditions That Are Neither Usual Care Nor No Treatment in Randomized Trials of Psychoeducational Palliative Care Interventions: A Systematic Review

BACKGROUND:

Determining intervention efficacy depends as much on the control group as on the intervention, but little attention has been given to the control condition in psychoeducational trials in palliative care.

OBJECTIVES:

To examine (1) research practice regarding control conditions that are neither usual care nor no-treatment controls in randomized trials of psychoeducational palliative care interventions and (2) the rationale and completeness of the descriptions of control conditions in trial reports.

METHODS:

PubMed, EMBASE, PsycINFO, and Web of Science were searched. After screening 1603 articles, 70 full-text articles were assessed for eligibility. The final sample included 9 trial reports. We used the Delphi list for quality assessment and the modified intervention taxonomy checklist to assess active intervention and control conditions.

RESULTS:

Four trials used an attention control designed to be equivalent to the structure of the active intervention. In another 4, the control condition included some aspects of attention control such that the mode of contact was similar to that in the active intervention, but either the amount or the intensity of attention was not similar. Only 3 trial reports explicitly stated the rationale for the choice of control condition. Although most reports contained delivery mode, materials, duration, frequency, and sequence, none described the qualifications or training required to deliver the control condition. Only 1 report mentioned the fidelity monitoring method, and none included fidelity data.

CONCLUSION:

Our review of psychoeducational trials in palliative care calls for researchers' attention to appropriate selection, design, conduct and report of control conditions.

Research on the alliance: Knowledge in search of a theory

OBJECTIVES

The aim of this review paper is to summarize the challenges facing research on the alliance now and going forward. The review begins with a brief overview of the development of the concept of the alliance in historical context.

METHOD

A summary of what has been accomplished both within the psychotherapy research community and in other professions is presented. Current challenges facing this line of research are identified, including the existence of a wide range of operational definitions that results in a diffusion of the identity of the alliance concept. It is argued that the current situation generates risks to incremental growth in several lines of research.

CONCLUSIONS

A case is made that a lack of clarity regarding how several variables within the broader category of therapeutic relationships fit together, overlap, or complement each other is also potentially problematic. Efforts to resolve the lack of a consensual definition are reviewed, and in conclusion, it is argued that a resumption of a conversation about the relationship in the helping context in general, and the alliance in particular, should be resumed.

Introduction: Applying Clinical Psychological Science to Practice

Mental illness is a prevalent and extraordinarily complex phenomenon. Psychologists have developed distinct approaches toward understanding and treating mental illness, rooted in divergent epistemology. This introduction to the Special Issue on Clinical Psychological Science and Practice provides a brief overview of the scientist-practitioner gap, and explores one step (of many) toward bridging this divide. Seven compelling case illustrations featured in this Special Issue apply empirical findings to case formulation, treatment selection, and assessment across complex and varied clinical presentations. This issue thereby demonstrates the feasibility of integrating research and clinical expertise in mental healthcare.

Our Best Selves

Psychotherapist expertise proves an urgent topic for practice and training, but insufficient research and conflicting definitions confound efforts to enhance expertise. In an ambitious article, Hill, Spiegel, Hoffman, Kivlighan, and Gelso offer a clear definition of expertise and propose broad indicators. In this reaction, we (a) laud the prominent psychologists for undertaking the Herculean task, (b) highlight points of convergence on relationships and responsiveness between their conclusions and those of others and ourselves, (c) take some collegial exceptions to their proposals and advance alternatives, and (d) underscore the probability that expertise resides far more in the person of the therapist than in specific methods. In particular, distinguishing expertise from experience, and separating expertise about psychotherapy from expertise demonstrated in session, will help to operationalize and cultivate it. The title of this commentary—“Our Best Selves”—embodies the conviction that developing the person of the therapist will most likely actualize expertise.

Editorial for Special Issue: Complexity within Cognitive Behaviour Therapy

As therapists we frequently use and hear the term ‘complexity’ in relation to clients, situations and settings. Although we may assume there is a shared understanding of what is meant by complexity, is this true? Do we really know what we mean by describing someone, or something, as complex? If we define complexity as ‘consisting of many different and connected parts, not easy to analyse or understand’ (Oxford English Dictionary, 2017), then we are probably describing intersections and interactions between different elements that can influence each other. Interestingly, the origin of the term derives from the Latin past participle plexus, meaning braided or entwined, which captures neatly the sense of the term ‘complex’ as meaning literally braided together. The breadth of this definition therefore may help to account for the diversity of the ways in which the term complexity is used in clinical settings. Continuing with the idea of the plait or braid, it also gives a sense of the number of threads or strands that could be incorporated within such a system. Complexity can derive from any source, and can interact with any part, so it can derive from the patient, the therapist, the therapeutic relationship or the healthcare setting; and each of these may interact with one or more parts. So from any source, complexity can affect processes and outcomes of care.

What is Good Psychotherapy?

This article addresses philosophical and methodological issues with regard to the question, “What is good psychotherapy?” Applying the ideas of Richard Bernstein, Hans-Georg Gadamer, Ludwig Wittgenstein, and other philosophers to the problem of discerning good psychotherapy, the author explores the conflict between foundationalism and the dynamic, interpersonal, and value-laden character of psychotherapy. The distinction between scientific knowledge, technical knowledge, and practical knowledge is also introduced, and implications with respect to the empirically validated treatment and manualized psychotherapy movements are discussed. An alternative is offered to the “good psychotherapy” question as currently posed, and examples of qualitative research exploring the meaning of “good therapy” as understood by specific therapists and clients are provided.

Outpatient Psychoanalytic Individual and Group Psychotherapy in a Nationwide Catamnestic Study in Germany

Unlike many (clinical) outcome projects, this study was designed to measure and evaluate the effects of individual and group-analytical psychotherapy performed in its most prevalent setting: outpatient treatment in the therapist's office. Drawing on a 20 percent sample of all members of the two main associations of psychoanalytical psychotherapists in Germany a one-page questionnaire was sent through their therapists to almost 1,000 former patients. The anonymous return rate was 65 percent. Subjects were asked for self-assessment of their physical, mental, social and overall health status at three points in time: at the beginning and end of their therapy and at the time of assessment (up to five years after completing therapy). Furthermore they were to report on their use of other health care services (visits to physicians, hospital stays, prescription drug consumption) and on their work-loss days. The responses show that the self-assessed health status of patients had improved significantly by the end of the therapy, and this effect had increased even more in the 2'4 years since completing therapy. The number of days in hospital declined on an average of two-thirds, visits to physicians by one-third and work-loss days by one-half Thus a substantial part of the cost of the therapy was saved in other parts of the health system. With the exception of a better cost-benefit relationship for group psychotherapy no significant differences were found in the salutary effects between group and individual forms of therapy.

Empirically Supported Treatments (ESTs) in Perspective

There is a strong movement toward employing only evidence-based treatments or empirically validated treatments (EVTs) in delivering psychological services. This movement is affecting professional practice, research, and training now and will continue to be influential far into the future. Efficacious treatments attempt to respond successfully to three prominent realms challenging psychology’s professional integrity: practicing psychologists’ applications, scientific certainty, and marketplace demands. In addition, training efficacy and adherence to ethical principles must be considered regarding adopting EVTs. Although the successful blending of these domains holds forth great potential for enriching training and practice, consolidating these areas may obscure elements essential to each pursuit. This article reviews both the merits and concerns the EVT movement holds forth for the counseling psychology profession. Recommendations are offered for integrating EVT knowledge into coursework and practica training.

Racism, Mental Health, and Mental Health Practice

In this article, the authors present an interdisciplinary discussion of the multiple dimensions of racism and formulate conceptions of its impact on the formation of healthy personalities. They describe how racism has both ideological and structural components and perpetuates itself recursively at the macro-(e.g., group, institution) and microlevels (e.g., interpersonal). As one consequence of its embedded, cyclical nature, efforts to treat client problems that involve issues of race and racism will necessarily entail piercing distortions in reality, encouraging self-moral development, and eliciting risk-taking behaviors. To take part in transforming current structures of racism, counseling psychologists are urged to extend these strategies beyond the therapeutic milieu. Implications for practice, training, and research are presented.

Principles of Empirically Supported Interventions in Counseling Psychology

The authors present background on the development of principles for the identification of empirically supported interventions in counseling psychology by the American Psychological Association’s Division 17 and include an overview of guiding considerations around which these principles were developed. As a context for these principles, the authors present a brief history of the social-economic-professional context within which the sometimes contentious movement toward the recognition of empirically supported treatments has developed within professional psychology. Seven principles for the consideration of the empirical support of counseling psychology interventions are presented along with discussion of the rationale behind each principle.

Feminist Interventions: Accountability Beyond Symptom Reduction

Feminist interventions to facilitate women's psychological well-being are forging new pathways to achieving the goals of the Decade of Behavior. In emphasizing the complex interplay between internal and external factors in women's lives, feminist interventions are designed to promote women's safety health, positive life styles, personal strength, competence, and resilience. In contrast, prevailing medical models locate the problem within the woman by concentrating on diagnosis and treatment of pathology and internal disorders. I offer a model here for implementing and assessing intervention strategies that targets both the effects of unsupportive or negative environments and the imperative to strengthen and empower girls and women, their families, and their communities. The obligation to be accountable for the outcomes of feminist interventions encompasses a major focus of this article. Evolving developments in research on accountability are reviewed in relation to conceptualization, goal setting, and assessment of feminist interventions. I encourage continuing collaboration between the feminist-informed research and practitioner communities to promote women's health, safety, and well-being in the Decade of Behavior and beyond.

A transdiagnostic minority stress treatment approach for gay and bisexual men's syndemic health conditions

Developing and deploying separate treatments for separate conditions seems ill-suited to intervening upon the co-occurring, and possibly functionally similar, psychosocial conditions facing gay and bisexual men. This article argues for the need to create transdiagnostic interventions that reduce multiple syndemic conditions facing gay and bisexual men at the level of their shared source in minority stress pathways. This article first reviews psychosocial syndemic conditions affecting gay and bisexual men, then suggests pathways that might link minority stress to psychosocial syndemics based on recent advancements in emotion science, psychiatric nosology, and cognitive-affective neuroscience, and finally suggests cross-cutting psychosocial treatment principles to reduce minority stress-syndemic pathways among gay and bisexual men. Because minority stress serves as a common basis of all psychosocial syndemic conditions reviewed here, locating the pathways through which minority stress generates psychosocial syndemics and employing overarching treatment principles capable of simultaneously alleviating these pathways will ultimately create a transdiagnostic approach to improving gay and bisexual men's health. Clinical research and training approaches are suggested to further validate the pathways suggested here, establish the efficacy of treatment approaches tied to those pathways, and generate effective methods for disseminating a transdiagnostic minority stress treatment approach for gay and bisexual men's psychosocial syndemic health.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

Using decision trees to characterize verbal communication during change and stuck episodes in the therapeutic process

Methods are needed for creating models to characterize verbal communication between therapists and their patients that are suitable for teaching purposes without losing analytical potential. A technique meeting these twin requirements is proposed that uses decision trees to identify both change and stuck episodes in therapist-patient communication. Three decision tree algorithms (C4.5, NBTree, and REPTree) are applied to the problem of characterizing verbal responses into change and stuck episodes in the therapeutic process. The data for the problem is derived from a corpus of 8 successful individual therapy sessions with 1760 speaking turns in a psychodynamic context. The decision tree model that performed best was generated by the C4.5 algorithm. It delivered 15 rules characterizing the verbal communication in the two types of episodes. Decision trees are a promising technique for analyzing verbal communication during significant therapy events and have much potential for use in teaching practice on changes in therapeutic communication. The development of pedagogical methods using decision trees can support the transmission of academic knowledge to therapeutic practice.

Implications of RDoC for the research and practice of psychotherapy

The field of psychotherapy is at an important juncture. Recent changes in the field include (a) the skeptical reception of the fifth edition of the Diagnostic and Statistical Manual and (b) NIMH's prioritization of an alternative classification system to guide translational and intervention research. Moreover, (c) the field continues to be held accountable to governmental agencies and third-party payers to demonstrate its empirical basis. Thus, psychological research as it relates to the practice of psychotherapy is at a crossroads. In this article, we provide a brief overview of several generations of psychotherapy outcome research, including the consequences that followed in the 1980s as psychotherapy research moved toward randomized controlled trials for clinical disorders. We delineate the inherent strengths and limitations of this movement and address how the NIMH has recently responded with the Research Domain Criteria (RDoC). We then address philosophical and practical implications of the emphasis on a neuroscientific conceptualization of psychological problems. Finally, we discuss opportunities for a next generation of convergent science that incorporates, rather than replaces, psychosocial variables across stages of translational research and treatment development.

Clinical experiences in using cognitive-behavior therapy to treat panic disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.

Efficacy combined with specified ingredients: a new direction for empirically supported addiction treatment

AIMS

With the increased need for sanctioning behavioral addiction treatments to guide key stakeholders, focus has shifted to developing and applying criteria for establishing empirically supported treatments (EST). Among the many criteria offered, demonstration of incremental efficacy over a placebo or comparison in at least two independent randomized clinical trials (RCTs) has been the gold standard. While necessary, the present EST criteria are not sufficient. The present work: (i) argues for empirically supported specificity in behavioral addiction treatment, (ii) explores the limitations of empirical support for EST efficacy without evidence of specificity and (iii) discusses implications and recommendations for ultimately raising the bar for status as an EST.

METHODS

The authors review relevant literature on ESTs, evidence-based practice and clinical trial design in the addictions and related disciplines.

RESULTS

We clarify that the additional bar of specificity does not denote uniqueness in causal processes and we argue that specificity should not be inferred only via the nature of the experimental contrast. Rather, a treatment has specificity if its active ingredients are identified and validated empirically as predictors of subsequent treatment-related outcomes. Within this new definition, there are implications for clinical research and other key stakeholders.

CONCLUSIONS

A heightened centrality of empirically supported addiction treatment ingredients moving forward will advance clinical knowledge and evaluation methodology at a far greater pace.

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.

A Study of Patients who go to a Psychology Clinic Seeking Treatment

In order to characterize a typical clinical context, as opposed to an academic or research context, this article will analyze the sociodemographic and clinical characteristics of patients who turn to a psychology clinic in need of professional help. This study was conducted using an initial sample of 1,305 patients at the Universidad Complutense de Madrid (UCM) Clínica Universitaria de Psicología. Of the sociodemographic characteristics studied, it is noteworthy that the majority of patients were women (65%) and relatively young (the average age is 29.7 years-old). The disorders for which psychological help was most often needed were anxiety and mood disorders and relationship problems, which together made up 50% of cases. In 17.70% of cases, patients had at least one comorbid disorder in addition to the one that brought them to the clinic. The generalizability and implications of the results are discussed.

Gay affirmative psychotherapy with lesbian, gay, and bisexual individuals: implications for contemporary psychotherapy research

Although a fair amount has been written about gay affirmative psychotherapy, there has not been a clear consensus on what actually constitutes gay affirmative therapy. Because there are no real theoretical framework, operational definitions, or outcome measures, pychotherapists are left unsure about how to incorporate it into their practice and researchers are unsure how best to investigate it. This article offers recommendations to identify gay affirmative therapy as a culturally competent approach for working with lesbian, gay, and bisexual clients and offers future research directions including how to utilize the "coming out" narrative in gay affirmative therapy.

Psychotherapie und Wissenschaft

Klinische Praxis und Psychotherapieforschung werden häufig als Spannungsfelder mit wenigen Berührungspunkten angesehen. Trotz erheblicher empirischer Erkenntnisgewinne über die letzten Jahrzehnte hinweg spielen in der klinischen Praxis oft Forschungsergebnisse nur eine untergeordnete Rolle für das Fällen von Therapieentscheidungen oder die Auswahl von Behandlungsstrategien. Stattdessen vertrauen Therapeuten häufig auf das eigene klinische Urteil, was beispielsweise zu einer Unterschätzung der Wahrscheinlichkeit von Therapiemisserfolgen führen kann. Flexible Behandlungskonzepte werden in der Praxis häufig standardisierten Interventionen bevorzugt, beispielsweise in der Annahme, letztere würden von Patienten nicht akzeptiert. Jedoch gibt es neben überzeugenden Wirksamkeitsnachweisen auch aktuelle Daten, die eine hohe Wertschätzung standardisierter Interventionen wie strukturierte Interviews durch Patienten belegen. Neue Studien zeigen, dass eine wissenschaftlich orientierte Ausbildung sowohl die Akzeptanz evidenzbasierter Behandlungsmöglichkeiten durch Therapeuten als auch den Therapieerfolg erhöhen können. Um eine breitere Dissemination von Ergebnissen aus der Forschung zu erreichen sowie evidenzbasierte Behandlung zu fördern, sollten Psychotherapieforscher ihre Ergebnisse Praktikern leichter zugänglich machen und angehende Psychotherapeuten müssen eine wissenschaftlich fundierte Ausbildung erhalten.

Evolução dos modelos de pesquisa em psicoterapia

O presente estudo apresenta uma revisão não sistemática da literatura sobre estudos de avaliação em psicoterapia, descrevendo e discutindo as três principais formas para realizá-la: eficácia, efetividade e processo. Os resultados revelaram uma expressiva evolução no curso das pesquisas sobre o tema, desde os pioneiros, passando pelos estudos de eficácia e efetividade (ainda presentes e dominantes) e chegando ao estudo do processo psicoterápico, especialmente com estudos de caso que são realizados de diversas maneiras pelos autores. Porém, também é possível constatar que ainda existem muitas dúvidas e perguntas sem respostas no campo da pesquisa em avaliação de psicoterapia. É possível que novas investigações sobre processo psicoterápico possam contribuir para diminuir estas lacunas.

Psychotherapy, psychopathology, research and practice: pathways of connections and integration

This paper describes three pathways of connections between different communities of knowledge seekers: integration of psychotherapeutic approaches, integration of psychotherapy and psychopathology, and integration of science and practice. Some of the issues discussed involve the delineation and investigation of common factors (e.g., principles of change), improvement of major forms of psychotherapy, clinical implications of psychopathology research, as well as current and future directions related to practice-research networks. The aim of this paper is to suggest that building bridges across theoretical orientations, scientific fields, professional experiences, and epistemological views may be a fruitful strategy to improve our understanding and the impact of psychotherapy.

Reminiscence and adaptation to critical life events in older adults with mild to moderate depressive symptoms

OBJECTIVES

The role of reminiscence as a way of adapting to critical life events and chronic medical conditions was investigated in older adults with mild to moderate depressive symptoms. Reminiscence is the (non)volitional act or process of recollecting memories of one's self in the past.

METHOD

171 Dutch older adults with a mean age of 64 years (SD = 7.4) participated in this study. All of them had mild to moderate depressive symptoms. Participants completed measures on critical life events, chronic medical conditions, depressive symptoms, symptoms of anxiety and satisfaction with life. The reminiscence functions included were: identity, problem solving, bitterness revival and boredom reduction.

RESULTS

Critical life events were positively correlated with identity and problem solving. Bitterness revival and boredom reduction were both positively correlated with depressive and anxiety symptoms, and negatively to satisfaction with life. Problem solving had a negative relation with anxiety symptoms. When all the reminiscence functions were included, problem solving was uniquely associated with symptoms of anxiety, and bitterness revival was uniquely associated with depressive symptoms and satisfaction with life. Interestingly, problem solving mediated the relation of critical life events with anxiety.

DISCUSSION

This study corroborates the theory that reminiscence plays a role in coping with critical life events, and thereby maintaining mental health. Furthermore, it is recommended that therapists focus on techniques which reduce bitterness revival in people with depressive symptoms, and focus on problem-solving reminiscences among people with anxiety symptoms.

Mapping the Future of Reminiscence: A Conceptual Guide for Research and Practice

Nearly 50 years after Butler’s seminal 1963 contribution, the field of reminiscence and life review is entering a more mature stage. Isolated examples of increasingly sophisticated studies have recently emerged that can serve as a sound, cumulative data base. However, the field lacks an overarching conceptual model describing emerging trends, neglected domains, and key linkages among component parts. In the present article, the authors selectively, yet critically, review prior limitations and promising developments and then describe a comprehensive, multifaceted conceptual model that can guide future research and practice. The authors initially situate their model within a particular theoretical orientation (i.e., life-span psychology). They then describe a heuristic model that identifies and discusses triggers, modes, contexts, moderators, functions, and outcomes. Finally, the authors illustrate how these interactive factors influence both theoretical and applied areas.

Reminiscence and mental health: a review of recent progress in theory, research and interventions

This article explores recent progress in theory, research and practical applications of reminiscence. It first describes the evidence for reminiscence as a naturally occurring process, and discusses the different functions of reminiscence and their relationships with mental health and lifespan processes. Three basic types of reminiscence that relate to mental health are specified: conversations about autobiographical memories and the use of personal recollections to teach and inform others have social functions; positive functions for the self include the integration of memories into identity, recollections of past problem-solving behaviours, and the use of memories to prepare for one's own death; negative functions for the self are the use of past memories to reduce boredom, to revive bitterness, or to maintain intimacy with deceased persons. It is proposed that in interventions the three types are addressed differently: simple reminiscence stimulates social reminiscence and bonding and promotes positive feelings; life review uses the positive functions to enhance personal wellbeing; and life-review therapy seeks to reduce the negative uses and thereby alleviate symptoms of mental illness. Studies of the effectiveness of interventions have provided some evidence that interventions are effective in relation to their goals. The review closes with recommended directions for future reminiscence research.