Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic

Objective The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment.Methods We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome.Results Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress.Conclusions Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy - in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.

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.

Practice-Oriented Research: An Introduction to New Developments and Future Directions

Aimed at understanding and improving psychological therapies as they are conducted in clinical routine, practice-oriented research (POR) is now a well-established approach to the scientific foundations of mental health care services. Resting on the accumulation of a wide range of practice-based evidence related to treatment outcome and process, as well as factors associated with the participants of psychotherapy and its context, POR is ripe for new developments - regarding what to investigate and how to investigate it. This paper is the introduction of a series devoted to recent advances and future directions of POR as their pertained to routine outcome monitoring, technologies and artificial intelligence, the integration of constructs and methods from program evaluation and implementation science, and the investigation of populations with limited financial resources across various regions of the world. The series also includes commentaries from two leaders of POR.

Therapists' and patients' experiences of using patients' self-reported data in ongoing psychotherapy processes-A systematic review and meta-analysis of qualitative studies

OBJECTIVE

Using patient-generated quantitative data in psychotherapy (feedback) appears to enhance treatment outcome, but there is variability in its effect. Different ways and reasons to implement routine outcome measurement might explain such variability. The goal of this review is to address the insufficient knowledge on how these data are used by therapists and patients.

METHODS

The present study is a systematic review and meta-analysis of qualitative reports of therapists' and patients' experiences using patient-generated quantitative data during ongoing psychotherapy.

RESULTS

Four main categories of use were identified: (1) uses of patients' self-reported data as nomothetic/objective markers for assessment, process monitoring, and treatment planning; (2) intrapersonal uses that enhance self-awareness, initiate reflection, and influence patients' mood or responses; (3) uses that prompt interactional processes by facilitating communication, supporting exploration, creating ownership in patients, changing treatment focus, enhancing therapeutic alliance, or disturbing the psychotherapy process; and (4) patients responding for specific purposes due to uncertainty and interpersonal motives, or strategic responding to achieve a desired result.

CONCLUSION

These results demonstrate that patient-reported data, when used in active psychotherapy, is very clearly not just an objective measurement of client functioning: the inclusion of patient-data has the potential to influence psychotherapy in numerous ways.

Therapeutic techniques and session impact: A practice-research network study in private practice

Objective: This study investigated the relationship between therapeutic techniques and session impact, by examining the replicability of findings observed in a university-based training clinic (Boswell et al., 2010) in another practice-oriented setting: private practice.

Method: N = 8 therapists completed session-level assessments of their technique use for N = 38 clients. The same client sample completed session-level assessments of session outcome. Technique-outcome associations were examined with multilevel models.

Results: As in Boswell et al., common factors were associated with positive session impact. For clients who received higher average common factor techniques (relative to their own therapist's caseload), session impact was the poorest in sessions with higher behavioral change techniques use (relative to the client's own average). Moreover, clients with the lowest average common factor techniques (relative to their therapist's caseload) reported better session impact in sessions that involved a higher degree of session-level behavioral change techniques (relative to their own average).

Conclusion: In line with Boswell et al., therapists should be mindful of the consistency of their routine technique use between- and within-clients, and this can be aided through collection of their own practice-oriented data.

Reconstructing dropout: Building from multiple definitions, therapist effects, and center effects

Objective: The literature regarding dropout from psychotherapy has suffered from issues of diverse operationalization of the construct. Some have called for a more uniform definition to aid in generalization across research; this study aimed to assess the viability of such a definition by examining the rate of occurrence for three distinct definitions simultaneously. In addition, therapist and center level variances are explored to further understand the differences between definitions.

Method: We compared the prevalence rates and overlap of three distinct operationalizations of dropout (based on last session attendance, therapist judgment, and symptom change) using data gathered from a national practice research network (N = 2977). Higher-order therapist and center-level effects were assessed for each definition.

Results: There was very little overlap among definitions, with less than one percent of clients simultaneously meeting criteria for all three definitions. Additionally, therapist and center effects were found for each definition, especially notable for therapist-rated and last-session attendance definitions of dropout.

Conclusion: Rather than a singular definition of dropout, these results instead suggest that multiple, specific, and unique definitions more accurately depict clinical reality, and future research might benefit from uncovering predictors of different "classes" of dropouts and examining the different practices of therapists and centers.

Baseline overly accommodating interpersonal problems in relation to parsed alliance-outcome associations in cognitive behavioral therapy for generalized anxiety disorder

Given its interpersonal underpinnings, relational factors may be salient in psychotherapy for generalized anxiety disorder (GAD). Supporting this point, research has indicated a positive total alliance-improvement correlation in cognitive behavioral therapy (CBT) for GAD. However, less research has disaggregated this correlation into within- and between-patient components, or examined theory-informed ways in which patient characteristics influence to these components. Thus, we first investigated parsed alliance-outcome associations in CBT for GAD. Second, consistent with theory that alliance may represent a direct interpersonal change correlate, we tested whether within-patient alliance improvements were especially therapeutic for patients with higher levels of an interpersonal problem prototypical of GAD-over accommodation. Also, consistent with theory that between-patient differences in overall alliance may be influenced by patients' preexisting relational characteristics, we tested whether more overly accommodating patients reported poorer average alliances that, in turn, related to worse outcomes.

Sixty-nine patients received variants of CBT. Patients rated over accommodation at baseline, and alliance and outcome across treatment.

As hypothesized, within-patient alliance improvements correlated with subsequent anxiety reduction, and this association was stronger for more overly accommodating patients. All between-patient associations were nonsignificant.

Results help clarify the nuanced role of alliance in CBT for GAD.

Client-Therapist Convergence on Sleep Difficulty and its Impact on Treatment Outcomes

While agreement between clients and their clinicians on therapy goals has frequently been investigated as a process-level variable (i.e., working alliance), dyadic convergence on presenting concerns is also important for initial case formulation. Transdiagnostic presenting problems, like sleep difficulty, pose a particular challenge for client-therapist convergence. The current study describes sleep difficulty in a treatment-seeking college population and investigates the impact of client and therapist baseline sleep problem reports on therapy outcomes.

Data were collected through a large practice research network, with the sample comprising 47,023 clients from 99 university counseling centers across the United States.

A larger proportion of clients (49.3%) had self-reported high baseline sleep difficulty than those with a clinician-identified sleep concern (16.0%). Clients with baseline sleep difficulty were more likely to end treatment with greater self-reported sleep difficulty and psychological symptom distress, although they may experience larger gross symptom change than clients without baseline sleep difficulty. Clinician-identified sleep concerns were significantly associated with client outcomes, particularly when clients did not report baseline sleep difficulty themselves.

Findings from this study suggest that it may be efficacious and efficient with limited time for treatment to address sleep concerns in a college setting.

Clinicians' attendance to their clients' transdiagnostic presenting concerns, like sleep difficulty, may increase clients' own awareness of problematic patterns of behavior. When time for therapy is short, as is often the case in college counseling, it may be efficient to prioritize these concerns with the potential to impact a broad range of symptoms.

Center Effects: Counseling Center Variables as Predictors of Psychotherapy Outcomes

Treatment context may have a unique impact on psychotherapy outcomes, above and beyond client, therapist, and therapy process variables. University counseling centers represent one such treatment context facing increasing treatment demands. This study examined the role of counseling centers and center variables in explaining differences in psychotherapy outcomes. The Center for Collegiate Mental Health, a large practice–research network, contained data from 116 counseling centers, 2,362 therapists, and 58,423 clients. Multilevel modeling tested if some counseling centers systematically achieved better outcomes than others (a “center effect”). Outcome was operationalized as clients’ magnitude and rate of change in distress across treatment. Results showed a relatively small “center effect” for both outcomes. Analyses sought to explain that center effect through administrative policies and characteristics. As a group, these variables partially explained the center effect. None explained a large portion of total outcome variance. Potential future implications for policy and advocacy efforts are discussed.

Multilevel versus single-level factor analysis: Differentiating within-person and between-person variability using the CCAPS-34

Objective: Although most self-report measures of distress are intended to assess time-varying constructs, they are usually developed using between-person data. They are therefore vulnerable to misspecification due to measurement nonequivalence at the between-person and within-person levels. In recent years, multiple studies have found that self-report distress may not be the same when considered over time versus between people: what changes over time may not be the same as what makes individuals different from one another. Method: In this study, we present a multilevel factor analysis (MFA) of a widely used multidimensional self-report measure of psychological symptoms, the Counseling Center Assessment of Psychological Symptoms-34 (CCAPS-34), in two samples (Ns: 1,223 and 757) of individuals with 10 or more observations each. We compare the results to traditional factor analysis. Results: Single-level factor analyses converged with the established seven-factor structure, regardless of sample or data subset. The MFA largely, but not entirely, recovered the existing factor structure of the CCAPS-34 at the within-person level in both samples, but not at the between-person level. The between-person factor structure was simpler than the within-person factor structure, particularly in the nonclinical sample in which only two factors were sufficient. Conclusions: The factors of this instrument that change over time appear to be narrow, while differences between people are broader. This argues against using general distress measures when assessing treatment outcomes. MFA is a promising method for measure development, even in data with relatively few observations per person. This method may clarify how self-report psychopathology manifests over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predicting future courses of psychotherapy within a grouped LASSO framework

Objective: There is a paucity of studies examining the experience of clients who undergo multiple courses of psychotherapy. Conducted within a large practice research network, this study demonstrated that returning therapy clients comprise a considerable portion of the clinical population in university counseling settings, and identified variables associated with return to therapy. Method: Utilizing data spanning 2013 to 2017, statistical variable selection for predicting return to therapy was conducted via grouped least absolute shrinkage and selection operator (grouped LASSO) applied to logistic regression. The grouped LASSO approach is described in detail to facilitate learning and replication. The paper also addresses methodological considerations related to this approach, such as sample size, generalizability, as well as general strengths and limitations. Results: Attendance rate, duration of initial treatment course, social anxiety, perceived social support, academic distress, and alcohol use were identified as predictive of return to therapy. Conclusions: Findings could help inform more cost-effective policies for session limits (e.g., extending session limits for clients with social anxiety), referral decisions (e.g., for clients with alcohol use problems), and appointment reminders (based on the association between poor attendance rate and return to therapy). Taking into account the many reasons that can explain why clients do or do not return to therapy, these findings also could inform clinicians' early case conceptualizations and treatment interventions.

Use of common and unique techniques in the early treatment phase for cognitive-behavioral, interpersonal/emotional, and supportive listening interventions for generalized anxiety disorder

Psychotherapy research often compares specific treatments to control conditions to establish efficacy of the specified treatment. Research has typically evaluated common factor elements (e.g., credibility, expectancy) in treatments only after the first or second session, largely as a manipulation check and under the assumption that such factors are static. This study observed therapist common factor and model-specific interventions in three treatment approaches from a randomized control trial for generalized anxiety disorder across the entire early phase of treatment (i.e., first five sessions). The parent randomized control trial compared two treatment conditions, using an additive design where patients were randomized to receive either interpersonal/emotional processing interventions or supportive listening after receiving a session of cognitive-behavioral therapy. The first five video-recorded sessions of N = 40 randomly sampled participants were observationally coded with a multidimensional intervention measure, with subscales reflecting diverse theoretical orientations and common factors. Multilevel modeling was used to examine intervention use and investigate differences between treatment conditions and segments. Among the results, common factor interventions were rated as significantly more typical in cognitive-behavioral therapy compared with supportive listening. The pattern of intervention use of other subscales was generally consistent with the orientation of the respective protocols. In the early phase of treatment, supportive listening conditions do not appear to function as common factor controls in the manner that many might assume. Common factors are potentially enhanced in bona fide treatments that include a more detailed, specific rationale and clear and cohesive techniques and goals. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Assessing and investigating clinicians' research interests: Lessons on expanding practices and data collection in a large practice research network

Conducted in naturalistic settings, practice-oriented research (POR) is aimed at building stronger connections between the science and practice of psychotherapy. Promoting the principles of POR, this article has 2 aims: (a) presenting the results of a survey assessing the interests of members of a large practice research network in topics that could guide future research conducted as part of clinical routine, and (b) describing difficulties in implementing a study in line with such interests. Despite the significant interest in and perceived clinical significance of two relationship constructs (alliance and countertransference), there were unique obstacles faced in their empirical investigation within an already operationally functional practice research network. Challenges in this process included resource-related difficulties (such as changes in staff and the time required to set up the study and administer the measures), logistics-related issues, and effectively incorporating the assessment procedure into an existing clinical system. The article also describes strategies to address these obstacles, with differing degrees of success, including the role of a "local champion" at each site, the importance of a personal/professional relationship between the researcher and participating centers, as well as the pragmatic assistance to sites during the preparation, coordination, and implementation process (e.g., providing templates and feedback on institutional review board applications, and technological assistance on how to incorporate the measures into existing center software). The article concludes with general recommendations and future directions for POR. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Are we in crisis? National mental health and treatment trends in college counseling centers

The current state of college student mental health is frequently labeled a "crisis," as the demand for services and severity of symptomatology have appeared to increase in recent decades. Nationally representative findings are presented from the Center for Collegiate Mental Health, a practice research network based in the United States, composed of more than 340 university and college counseling centers, in an effort to illuminate trends in symptom severity and patterns in treatment utilization for the campus treatment seeking population. Clinical data collected over 5 academic years (2010-2015) showed small but significantly increasing trends for self-reported distress in generalized anxiety, depression, social anxiety, family distress, and academic distress, with the largest effect sizes observed for generalized anxiety, depression, and social anxiety. On the other hand, a significantly decreasing trend was observed for substance use. No significant changes were observed for eating concerns and hostility. Utilization data over 6 years indicated a gradual yet steady increase in the number of students seeking services (beyond the rate expected with increasing institutional enrollment), as well as increases in the number of appointments scheduled and attended, with great variation between centers. Within the context of changing national trends, we conclude that it is advisable to consider the specific needs of local centers to best accommodate distinct student bodies. (PsycINFO Database Record

Effectiveness of routine psychotherapy: Method matters

OBJECTIVE

Though many studies have shown that psychotherapy can be effective, psychotherapy available in routine practice may not be adequate. Several methods have been proposed to evaluate routine psychological treatments. The aim of this paper is to demonstrate the combined utility of complementary methods, change-based benchmarking, and end-state normative comparisons, across a range of self-reported psychological symptoms.

METHOD

Benchmarks derived from randomized controlled trials (RCTs) and normative comparisons were used to evaluate the effectiveness of psychotherapy in a large (N = 9895) sample of clients in university counseling centers (UCCs).

RESULTS

Overall, routine psychotherapy was associated with significant improvement across all symptoms examined. For clients whose initial severity was similar to RCT participants, the observed pre-post effect sizes were equivalent to those in RCTs. However, treatment tended to lead to normative end-state functioning only for those clients who were moderately, but not severely, distressed at the start of psychotherapy.

CONCLUSIONS

This suggests that although psychotherapy is associated with an effective magnitude of symptom improvement in routine practice, additional services for highly distressed individuals may be necessary. The methods described here comprise a comprehensive analysis of the quality of routine care, and we recommend using both methods in concert. Clinical or methodological significance of this article: This study examines the effectiveness of routine psychotherapy provided in a large network of counseling centers. By comparing multiple established methods to define outcomes in this sample we provide a detailed understanding of typical outcomes. The findings show that, across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress. However, there is room to improve, especially by increasing the number of clients who return to normal functioning by the end of treatment. Using distinct methods provides complementary answers to the question: How effective is routine psychotherapy?

Therapist effects on dropout from a college counseling center practice research network

Dropout has been a pervasive and costly problem in psychotherapy, particularly for college counseling centers. The present study examined potential predictors of dropout using a large data set (N = 10,147 clients, 481 therapists) that was gathered through a college counseling center practice research network as a replication and extension of recent findings regarding therapist effects on dropout. The final model resulted in a dropout rate of 15.9% and a therapist effect of 9.51% on dropout variance. Therapist demographic variables were investigated, though none were found to be significant. Variables found to be predictive of increased likelihood of dropping out included higher levels of general presenting concerns, alcohol-related distress, and current financial stress. Ultimately, this study showed that therapists may play an important role in the likelihood of client dropout, and that additional research should be conducted to identify additional predictors, particularly at the therapist and center level. (PsycINFO Database Record

Treatment Outcome Package: Measuring and facilitating multidimensional change

The Treatment Outcome Package (TOP; D. R. Kraus, Seligman, & Jordan, 2005) is a multidimensional routine progress and outcome measure developed for use in diverse naturalistic practice settings. In this article, we (a) provide a brief review and summary of the extant psychometric and research support for the TOP, (b) provide examples of the TOP's use in clinical training and practice, and (c) discuss the implications of the TOP for future psychotherapy training, research, and practice. In particular, we focus on the implications of risk-adjusted progress monitoring for systems of care and mental health care decision making.

Building clinicians-researchers partnerships: lessons from diverse natural settings and practice-oriented initiatives

In this concluding paper, we identify the type of studies conducted by 11 teams of contributors to a special issue on building clinicians-researchers partnerships. Those studies were conducted across a variety of clinical settings. We also integrate the lessons that have emerged from their collaborative initiatives in terms of obstacles faced, strategies adopted to address these challenges, benefits gained, and general recommendations offered to facilitate studies conducted with or by clinicians. The paper ends with the authors' thoughts about the future success of practice-oriented research in general.

Adult attachment as a moderator of treatment outcome for generalized anxiety disorder: Comparison between cognitive-behavioral therapy (CBT) plus supportive listening and CBT plus interpersonal and emotional processing therapy

OBJECTIVE

To determine whether baseline dimensions of adult insecure attachment (avoidant and anxious) moderated outcome in a secondary analysis of a randomized controlled trial comparing cognitive-behavioral therapy (CBT) plus supportive listening (CBT + SL) versus CBT plus interpersonal and emotional processing therapy (CBT + I/EP).

METHOD

Eighty-three participants diagnosed with generalized anxiety disorder (GAD) were recruited from the community and assigned randomly to CBT + SL (n = 40) or to CBT + I/EP (n = 43) within a study using an additive design. PhD-level psychologists treated participants. Blind assessors evaluated participants at pretreatment, posttreatment, 6-month, 12-month, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale, Clinician's Severity Rating). Avoidant and anxious attachment were assessed using self-reported dismissing and angry states of mind, respectively, on the Perceptions of Adult Attachment Questionnaire.

RESULTS

Consistent with our prediction, at all assessments higher levels of dismissing styles in those who received CBT + I/EP predicted greater change in GAD symptoms compared with those who received CBT + SL for whom dismissiveness was unrelated to the change. At postassessment, higher angry attachment was associated with less change in GAD symptoms for those receiving CBT + I/EP, compared with CBT + SL, for whom anger was unrelated to change in GAD symptoms. Pretreatment attachment-related anger failed to moderate outcome at other time points and therefore, these moderation effects were more short-lived than the ones for dismissing attachment.

CONCLUSIONS

When compared with CBT + SL, CBT + I/EP may be better for individuals with GAD who have relatively higher dismissing styles of attachment.

Attachment history as a moderator of the alliance outcome relationship in adolescents

The role of the alliance in predicting treatment outcome is robust and long established. However, much less attention has been paid to mechanisms of change, including moderators, particularly for youth. This study examined the moderating role of pretreatment adolescent-caregiver attachment and its impact on the working alliance-treatment outcome relationship. One hundred adolescents and young adults with primary substance dependence disorders were treated at a residential facility, with a cognitive-behavioral emphasis. The working alliance and clinical symptoms were measured at regular intervals throughout treatment. A moderator hypothesis was tested using a path analytic approach. Findings suggested that attachment to the primary caregiver moderated the impact of the working alliance on treatment outcome, such that for youth with the poorest attachment history, working alliance had a stronger relationship with outcome. Conversely, for those with the strongest attachment histories, alliance was not a significant predictor of symptom reduction. This finding may help elucidate alliance-related mechanisms of change, lending support for theories of corrective emotional experience as one function of the working alliance in youth psychotherapy.

Clinical experiences in conducting cognitive-behavioral therapy for social phobia

Several authors have identified a disconnect between psychotherapy research, including research on cognitive behavioral therapy (CBT), and real-world psychotherapy practice. This disconnect has several negative consequences, potentially including less-than-optimal practice standards as well as a lack of input from practicing psychotherapists on how research can be improved and made more relevant in their day-to-day clinical work. As part of an ongoing effort to engage practicing psychotherapists in a feedback loop with psychotherapy researchers, this study reports the results of a survey of CBT therapists who have used CBT in the treatment of social phobia (SP). The survey was designed primarily to document how often certain potential problems, identified by expert researchers and CBT manuals, actually act as barriers to successful treatment when CBT is employed in nonresearch environments. The participants were 276 psychotherapists responding to email, online, and print advertisements completing the online survey. Participants varied considerably in psychotherapy experience, work environment, experience in using CBT for SP, and in some ways varied in their usual CBT techniques when treating SP. Among the most prominent barriers identified by many of the participants were patient motivation, comorbidity, logistical problems (especially with exposures), patient resistance, and severity and chronicity of SP symptoms. These findings may be useful for psychotherapy researchers as areas for potential study. The results may also suggest topics requiring clinical guidelines, innovations within CBT, and dissemination of successful techniques to address the barriers identified here.

On the dissemination of clinical experiences in using empirically supported treatments

This article addresses the long-standing gap that has existed between psychotherapy research and practice and the efforts that have been made to bridge it. It also introduces one such effort, which has consisted of 3 clinical surveys on the experiences of practitioners in using empirically supported treatments for panic disorder, social anxiety, and OCD. In contrast to attempts to close the gap by disseminating research findings to the clinician, the clinical surveys are intended to allow for practitioners to disseminate their clinical experiences to the researcher-and also to other clinicians. What we view as a "two-way bridge" initiative is a collaboration between the Society of Clinical Psychology, Division 12 of the APA, and the Psychotherapy Division of the APA-Division 29. The mechanism that has been established provides a way for clinicians to be a part of the research process, which we hope will provide evidence that can help to enhance our clinical effectiveness.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Psychotherapy outcome: an issue worth re-revisiting 50 years later

Responding to an invitation to celebrate the 50th anniversary of the journal Psychotherapy, the goal of this article is to describe three general ways by which the impact of psychotherapy might be improved: (a) clinically, by encouraging the assimilation of empirically based principles of change and psychopathology research into day-to-day practice; (b) empirically, by fostering process and outcome research focused on a wide range of common factors and basic findings; as well as (c) clinically and empirically, by facilitating active collaboration of practitioners and researchers in various types of practice-oriented research. Reflected in these three potential avenues of growth are the assumptions that (a) we can improve our understanding and impact of psychotherapy by building on convergences and complementarities across different theoretical orientations, domains of research, and professional expertise, and that (b) most of the clinical and research suggestions derived by such convergence and plurality may not require drastic changes in the practice of many psychotherapists.