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Objective: How are collaborative interactions associated with clients' progress in therapy? This study addressed this question, by assessing the quality of therapeutic collaboration and comparing it passage by passage with the clients' assimilation of problematic experiences in two cases of major depression treated with Cognitive Behavioral Therapy, one recovered and one improved-but-not-recovered., Method: We used the Therapeutic Collaboration Coding System to code collaborative work and the Assimilation of Problematic Experiences Scale (APES) to rate clients' progress. In both cases, for the distribution of specific collaborative therapeutic exchanges, we tested for the difference of empirical means between lower and higher APES levels., Results: Both cases progress in APES, but in contrast with Annie (Improved-but-not-recovered), Kate (Recovered) achieved higher levels of change in last sessions. In addition, we found significant differences in the types of collaborative therapeutic exchanges associated with lower and higher APES levels., Conclusion: Ambivalent therapeutic exchanges distinguished the recovered case from the not recovered case highlighting a source of difficulties in facilitating therapeutic change in CBT. In addition, observations in these cases supported the theoretical suggestion that supporting interventions would be better accepted at lower APES levels, whereas challenging interventions would be better accepted at higher APES levels.

The assimilation model describes therapeutic change as an integration of experiences that had previously been problematic, distressing, avoided, or warded off. This study assessed whether assimilation was associated with treatment outcome in a sample of psychotherapeutic treatments for depression. Further, it assessed the direction of the association-whether increasing assimilation predicted decreases in symptom intensity or decreasing symptom intensity predicted increases in assimilation., Method: Participants were 22 clients with mild to moderate depression drawn from a clinical trial comparing cognitive behavioral therapy with emotion-focused therapy. The direction of prediction between assimilation progress and changes in self-reported symptom intensity was assessed., Results: The assimilation progress was shown to be a better predictor of decreases in symptom intensity than the reverse., Conclusion: The results supported the assimilation model's suggestion that assimilation progress promotes decreases in symptom intensity in the treatment of clients with major depressive disorder., (Copyright © 2017 The Authors. Clinical Psychology & Psychotherapy Published by John Wiley & Sons Ltd.)

The assimilation model describes the change process in psychotherapy. In this study we analyzed the relation of assimilation with changes in symptom intensity, measured session by session, and changes in emotional valence, measured for each emotional episode, in the case of a 33-year-old woman treated for depression with cognitive-behavioral therapy. Results showed the theoretically expected negative relation between assimilation of the client's main concerns and symptom intensity, and the relation between assimilation levels and emotional valence corresponded closely to the assimilation model's theoretical feelings curve. The results show how emotions work as markers of the client's current assimilation level, which could help the therapist adjust the intervention, moment by moment, to the client's needs.

Objective: This study examined the therapist activities immediately preceding assimilation setbacks in the treatment of a good-outcome client treated with linguistic therapy of evaluation (LTE)., Method: Setbacks (N = 105) were defined as decreases of one or more assimilation stages from one passage to the next dealing with the same theme. The therapist activities immediately preceding those setbacks were classified using two kinds of codes: (a) therapist interventions and (b) positions the therapist took toward the client's internal voices., Results: Preceding setbacks to early assimilation stages, where the problem was unformulated, the therapist was more often actively listening, and the setbacks were more often attributable to pushing a theme beyond the client's working zone. Preceding setbacks to later assimilation stages, where the problem was at least formulated, the therapist was more likely to be directing clients to consider alternatives, following the LTE agenda, and setbacks were more often attributable to the client following these directives shifting attention to less assimilated (but nevertheless formulated) aspects of the problem., Conclusions: At least in this case, setbacks followed systematically different therapist activities depending on the problem's stage of assimilation. Possible implications for the assimilation model's account of setbacks and for practice are discussed.

Objective: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes., Methods: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P)., Results: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments., Conclusions: These results suggest different change processes are at work in CBT and PIT.

Background: The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy., Aim: We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system - the therapeutic collaboration coding system (TCCS) - designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding system's psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the client's therapeutic zone of proximal development, defined as the space between the client's actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist., Method: We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy., Conclusion: The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship., (© 2012 The British Psychological Society.)

The assimilation model suggests progress in psychotherapy follows an eight-stage sequence described by the Assimilation of Problematic Experiences Scale (APES). This study sought to reconcile this developmental stage model with the common but superficially contradictory clinical observation that therapeutic advances alternate with setbacks. Setbacks (n=466) were identified in therapy transcripts of two clients and classified using a preliminary nine-category list of possible alternative reasons for setbacks. Most of the setbacks involved switches among the multiple strands of a problem due to (a) therapists exceeding clients' therapeutic zone of proximal development, (b) therapists guiding clients to shift toward relatively problematic material (balance metaphor), or (c) spontaneous switches. Rather than contradicting the theory, this close examination of setbacks yielded elaborations of it.

Background: Psychotherapy's equivalence paradox is that treatments tend to have equivalently positive outcomes despite non-equivalent theories and techniques. We replicated an earlier comparison of treatment approaches in a sample four times larger and restricted to primary-care mental health., Method: Patients (n=5613) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) or psychodynamic therapy (PDT) at one of 32 NHS primary-care services during a 3-year period (2002-2005) completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) at the beginning and end of treatment. Therapists indicated which approaches were used on an End of Therapy form. We compared outcomes of groups treated with CBT (n=1045), PCT (n=1709), or PDT (n=261) only or with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1 (n=1035), PCT+1 (n=1033), or PDT+1 (n=530), respectively., Results: All six groups began treatment with equivalent CORE-OM scores, and all averaged marked improvement (overall pre/post effect size=1.39). Neither treatment approach nor degree of purity ('only' v. '+1') had a statistically significant effect. Distributions of change scores were all similar., Conclusions: Replicating the earlier results, the theoretically different approaches tended to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, incomplete data, and other issues. Insofar as these routine treatments appear effective for patients who complete them, those who fail to complete (or to begin) treatment deserve attention by researchers and policymakers.

Using the assimilation model, we describe a theoretical paradox in which interpersonally assertive parts of the depressed person's personality are dominated and suppressed by parts that are interpersonally submissive and passive. We examine the relevance of this paradox to therapeutic work, focusing on a particularly helpful session (according to the therapist) from the case of Joan, a woman seen for depression in cognitive-behavioral therapy. We consider how the therapist intervened to enhance communication between the interpersonally submissive and dominant parts of Joan and discuss the implications of this process for therapy with such clients.

Background: Psychotherapy's equivalence paradox is that treatments have equivalently positive outcomes despite non-equivalent theories and techniques. We compared the outcomes of contrasting approaches practised in routine care., Method: Patients (n = 1309) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) and psychodynamic therapy (PDT) at one of 58 National Health Service (NHS) primary and secondary care sites in the UK during a 3-year period completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. Therapists indicated which treatment approaches were used on an End of Therapy form. We compared outcomes of six groups: three treated with CBT, PCT or PDT only, and three treated with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1, PCT+1 or PDT+1 respectively., Results: All six groups averaged marked improvement (pre-post effect size = 1.36). Treatment approach and degree of purity ('only' vs. '+1') each accounted for statistically significant but comparatively tiny proportions of the variance in CORE-OM scores (respectively 1% and 0.5% as much as pre-post change). Distributions of change scores were largely overlapping., Conclusions: Results for these three treatment approaches as practised routinely across a range of NHS settings were generally consistent with previous findings that theoretically different approaches tend to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, lack of a control group, missing data and other issues.

Of 76 clients receiving 8-20 sessions of cognitive therapy (CT) in a joint university and a national health service clinic, 31 experienced sudden gains that appeared very similar to those first reported in clinical trials of CT by T. Z. Tang and R. J. DeRubeis (1999) and subsequently replicated in other studies. The sudden gains appeared less stable in the present study's more routine clinical practice settings than they were in the clinical trials. Life events did not appear to account for sudden gains., (Copyright 2005 APA.)

Objectives: The aims of this study were to use symptom intensity measures collected at each session (1) to describe the outcomes of clients who received cognitive therapy (CT) for depression in a clinically representative sample, and (2) to compare the outcomes of clients who completed the agreed number of sessions with those who did not., Design and Method: Clients (N = 58) contracted to attend between 12 and 20 sessions of CT completed the Beck Depression Inventory (BDI) immediately prior to each therapy session. The BDI and other measures were collected at intake and, for those who completed therapy, at a post-therapy assessment., Results: Completers' BDI scores improved significantly from intake to post-treatment and significantly more from intake to their final session than did those of non-completers. However, when non-completers' final session scores were matched with scores of randomly selected completers at the corresponding session, the difference in improvement was not significant. A significantly higher proportion of clients who completed the agreed number of sessions achieved reliable and clinically significant change (71.4%, 25/35), compared with just 13% (3/23) of clients who did not., Conclusions: (1) CT for depression can be effective in a clinically representative population. (2) Attrition from clinical trials may bias estimates of treatment effectiveness.

Sudden gains--large, enduring reductions in symptom intensity from one session to the next--were identified by T. Z. Tang and R. J. DeRubeis (1999b) on the basis of data from 2 manualized clinical trials of cognitive therapy for depression. The authors found similar sudden gains among clients with a variety of disorders treated with a variety of approaches in routine clinic settings. Clients (N = 135 who met inclusion criteria) completed short forms of the Clinical Outcomes in Routine Evaluation (CORE-SF) preceding 7 to 74 individual sessions. Those who experienced sudden gains within their first 16 sessions (n = 23) had significantly lower CORE-SF scores in their final 3 sessions than did the other clients.

The present study utilized an empirically derived coding system to identify content categories in the spontaneous verbalizations of social phobics in the context of a short-term cognitive-behavioral group therapy. The coding system was applied successfully to segments of transcriptions of eleven group sessions. Evaluation of changes in the content categories utilized by two subjects over the course of the life of the group indicates the usefulness of this coding system in identifying meaningful shifts in cognitive processes during treatment.

We present three current, complementary formulations of the assimilation model: (a) the schema formulation, based on cognitive developmental concepts: (b) the voices formulation, in which assimilation is understood as the construction of a meaning bridge between active internal voices; and (c) the cognitive science formulation, which uses cognitive concepts of memory types to understand the failure of memory in cases of warded-off and avoided experiences. These views of assimilation are used to understand the varied functions that narratives (stories about real or imagined events outside of therapy) may play in psychotherapy, including narratives that avoid encounters with threatening material, narratives that approach such material indirectly or symbolically, narratives by which clients reexperience trauma, and narratives that help construct a mature understanding.

Objectives: We used a new instrument, the Agnew Relationship Measure (ARM), to examine the alliance's dimensionality and to construct scales for use in future studies., Design: We studied the alliance as reported on the ARM by both clients and therapists in the Second Sheffield Psychotherapy Project, a randomized comparison of two contrasting time-limited psychotherapies for depression., Methods: Clients (N = 95) and therapists (N = 5) completed parallel forms of the (ARM) after every session (N = 1120)., Results: Five scales were constructed, based on results of simultaneous components analyses and considerations of conceptual coherence and comparability across client and therapist perspectives., Conclusions: Bond, partnership, and confidence overlapped statistically (consistent with previous studies), but there are conceptual and empirical reasons for retaining the distinctions. Openness represented a relatively independent dimension. The client initiative scale had low internal consistency but the items may have value for future investigations.

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Depressed psychotherapy clients (N = 117) rated the treatment principle credibility of cognitive-behavioural (CB) and psychodynamic-interpersonal (PI) before they were randomly assigned to receive either eight or 16 sessions of one of these treatments, and they rated their expectations of the treatment to which they were assigned immediately before (initial credibility) and immediately after their first session (emergent credibility). Results indicated that before they were assigned to a treatment, clients rated CB treatment principle credibility higher than PI treatment principle credibility. After assignment, however, clients rated initial credibility similar regardless of whether they were assigned to CB or PI therapy, and their ratings of emergent credibility increased to a similar degree from immediately before to immediately after the first session in both treatments. Clients' endorsement of CB and PI treatment principle credibility predicted improvement in PI therapy but not improvement in CB therapy. Initial and emergent credibility of clients' assigned treatment predicted improvement for clients who received eight sessions of therapy, but not for clients who received 16 sessions of therapy. The implications of these findings are discussed.

A verbal exchange is a set of 2 people's co-occurring speech-act categories that accomplish some subtask within an interpersonal encounter. Factor analysis of verbal response mode (speech act) frequencies in 1,630 segments (each approximately 10 to 12 min) drawn from the brief psychodynamic-interpersonal or cognitive-behavioral treatment of 39 mainly depressed clients identified 6 exchanges in each treatment--4 that were the same in both treatments (Revealing, Storytelling, Explaining, and Inquiring) and 2 that distinguished each treatment (Exploring and Interpreting in psychodynamic-interpersonal treatment; Prescribing and Reframing in cognitive-behavioral treatment). The exchanges showed distinctive temporal patterns across segments of sessions and across sessions of each time-limited treatment. The verbal exchange is a midsize concept that links atomistic verbal codes with clinical or theoretical concepts.

The drug metaphor suggests that if a process component (e.g., interpretation) is an active ingredient of a successful psychotherapy, then administering a relatively high level of it should yield a relatively positive outcome, and levels of the process component and the outcome should be correlated across clients. Measures of 5 theoretically relevant, reliably measured verbal process components were compared with the rate of change in 3 standard symptom intensity measures across the brief treatments of 39 (mainly depressed) psychotherapy clients. The expected significant process-outcome correlations were not found. These results are discussed as they illuminate some misleading assumptions that underlie many conventional studies of psychotherapy process and outcome.

Further analysis of outcome data from the Sheffield Psychotherapy Project suggested that one of the principal therapists was responsible for most of the reported advantage of Prescriptive over Exploratory treatment.