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Using the Coding System of Therapeutic Focus, this exploratory study was a comparative process analysis of clinically significant sessions obtained from 22 master cognitive-behavior and 14 master psychodynamic-interpersonal therapists. Therapists were nominated by experts in each of these orientations, and clients were seen in a naturalistic setting for problems with anxiety, depression, or both. Relatively few between-groups differences emerged with this master therapist sample. However, regardless of theoretical orientation, several differences were found between those portions of the session labeled by therapists as being clinically significant and those viewed as less significant. As these findings are different from those obtained in a previous study of the therapeutic focus in interventions carried out within the context of a controlled clinical trial, some of the possible factors contributing to these differences are noted.

In the analysis of the impact of clinical interventions, the received wisdom has been that posttreatment scores, with pretreatment scores equated by random assignment or statistically partialed out, should be used to evaluate treatment outcomes. However, posttreatment scores are not generally more reliable than, nor equivalent to, change scores, even with pretreatment scores partialed out of both. Moreover, there are data-analytic methods that indicate how individual patients change, in terms of response curves over time, rather than indicate only how much groups change on the average. These methods take researchers back to the individual data that they ought to use for choosing the specific models of change to be used. To maximize relevance for clinical practice, the results of treatment research should always be reported at this most disaggregated or individual change level, as well as, when appropriate, at more aggregated statistical levels.

Clients (n = 79) and therapists (n = 5) rated their alliance using parallel forms of the Agnew Relationship Measure (ARM) after every session of their time-limited psychodynamic-interpersonal or cognitive-behavioral treatments for depression. The ARM assesses 5 dimensions of the alliance: Bond, Partnership, Confidence, Openness, and Client Initiative. Treatment outcome was assessed as residual gain from pretreatment assessment to end of treatment, 3-month follow-up, and 1-year follow-up on 6 standard measures. Some aspects of the alliance as measured by the ARM were correlated with clients' gains in treatment. The strength of the association varied across assessment measures, occasions of outcome assessment, ARM scales, and the session number when the alliance was measured.

This study examined whether voucher delivery arrangements affect treatment outcome. First, 90 cocaine-dependent adults were randomly assigned to behavioral counseling or counseling plus vouchers for cocaine-free urine samples. The value of each voucher was low at the beginning but increased as the patient progressed (Voucher Schedule 1). Voucher Schedule 1 produced no improvements relative to counseling only. Next, 23 patients received vouchers on either Voucher Schedule I or Voucher Schedule 2. Voucher Schedule 2 began with high voucher values, but requirements for earning vouchers increased as the patient progressed. Average durations of cocaine abstinence were 6.9 weeks on Voucher Schedule 2 versus 2.0 weeks on Voucher Schedule 1 (p = .02). This confirms that vouchers can assist in initiating abstinence and that voucher delivery arrangements are critical.

The characteristics involved in cultural competency in psychotherapy and counseling have been difficult to specify. This article describes attempts to study factors associated with cultural competency and addresses 3 questions. First, is ethnic match between therapists and clients associated with treatment outcomes? Second, do clients who use ethnic-specific services exhibit more favorable outcomes than those who use mainstream services? Third, is cognitive match between therapists and clients a predictor of outcomes? The research suggests that match is important in psychotherapy. The cultural competency research has also generated some controversy, and lessons learned from the controversy are discussed. Finally, it is suggested that important and orthogonal ingredients in cultural competency are therapists' scientific mindedness, dynamic-sizing skills, and culturespecific expertise.

This article provides an overview of methodological and conceptual issues underlying the assessment of change during psychotherapy with children and families. Three central considerations are discussed: (1) What changes do we measure? (2) When do we measure change? (3) How do we measure change? The difficulties with the traditional methods of assessing change are highlighted, and suggestions for a new paradigm that calls for expansion of the homological network relevant to the analysis of change, as well as the inclusion of more assessment points and more reliable and valid measures of the change process, are presented. Illustrations of key points are provided from the Adolescent Transitions Program, a theoretically based intervention program targeting high-risk youth. KEY WORDS: Measurement of change; psychotherapy; change item; reliability; antisocial behavior; coercion theory.

This article identifies and addresses three methodological domains relevant to the treatment of anxiety disorders in youth: (a) procedural matters, (b) the assessment of anxious distress, and (c) the analysis of treatment-produced change. Procedural topics include the need to manualize treatment, have diversity among participants and comparability of the duration of treatment and control conditions, and control for medication status. Multiple-method measurement issues include child and parent reports, observations, and structured interviewing. Our examination of change issues considers comorbidity, analyzing the intent-to-treat sample, treatment 'spillover,' and clinical as well as statistical significance. Problems are identified and potential ameliorative strategies are offered. KEY WORDS: Anxiety; therapy research methods; child treatment; clinical and statistical significance; anxiety measurement.

In this paper, we define psychotherapy as a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathologic conditions and functional impairment through focus on the therapeutic relationship; the patient's attitudes, thoughts, affect, and behavior; and social context and development. The possible mechanisms of action and active ingredients of psychotherapy in children and adolescents are discussed, with an emphasis on the above-noted domains. The adult psychotherapy literature strongly supports the central roles of the therapeutic relationship and therapeutic empathy; this has been much less intensively explored in the child and adolescent psychotherapy literature. Similarly, there have been few studies examining the mediation of treatment effects by impact on specific domains. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating psychosocial and biological variables on outcome and course. The results of such studies can aid further refinements in both theories of etiology and improvement in treatments for children and adolescents. KEY WORDS: Psychotherapy; treatment models; theories of etiology; mechanisms of psychotherapy effectiveness; conceptualization of psychotherapy

A method of assessing outcome after psychotherapy in private practice or clinics is described. Use of this system is illustrated by reference to the progress and rate of recovery of 27 patients seen by a private practice clinician in comparison with base rates from a prior study. The results suggested more rapid recovery in the patients treated by an experienced clinician committed to a brief, solution-focused psychotherapy. The methodology reported, based on weekly assessment of patient progress and the use of clinical significance markers, has implications for routine clinical practice as well as for managed health care practices and social policy decisions.

It is important to define precisely what is and is not meant by 'empirically supported treatments,' rigorously based on what is actually known about the nature of experimental therapy research. The criteria for empirically supported treatments merely allow conclusions about whether treatments cause any change beyond the causative effect of such factors as placebo or the passage of time. Applied implications are limited, due to external validity and to the fact that applied decisions are influenced by cost-benefit analyses. Creating increasingly effective therapies through between-group designs is best done by controlled trials specifically aimed at basic questions about the nature of psychological problems and the nature of therapeutic change mechanisms. Naturalistic research is important for external validity but is valuable only if it uses scientifically valid methods to address basic knowledge questions.

Objective: The purpose of this study was to explore the therapeutic treatment provided by mental health practitioners in cases involving physical child abuse to describe generally the amount and type of treatment provided to the abused child and other significant people involved in the abuse. Method: An instrument was designed to determine what therapeutic treatment was provided by practitioners in the previous year and sent to 689 mental health workers in the state of Kentucky: Licensed Clinical Social Workers, Clinical Members of the American Association of Marriage and Family Therapists, and Kentucky Department of Social Services Caseworkers. Results: The family was seen as the primary client most frequently with the focus of therapy being to provide a safe environment for the child or to improve family relationships. Abused children were found to receive only seven of the 23 sessions generally provided in these cases to overcome the deleterious effects of the abuse. Conclusions: The findings indicate that physically abused children may need more treatment to overcome their traumatic experiences. Since the family and the perpetrator have therapeutic requirements, these services need to be additional sessions. While the safety of the child is of paramount importance, the victim needs appropriate and effective treatment to surmount the detrimental consequences of the maltreatment. Key Words - Therapy, Child abuse.

Assigning clients to treatments on the basis of their differential aptitudes for those treatments may reduce variability and improve the mean outcomes of psychotherapy. The assimilation model suggests that in time-limited treatments, clients with well-assimilated problems would do better in cognitive or behavioral therapies than in psychodynamic, experiential, or interpersonal therapies, whereas the reverse should be the case for clients with poorly assimilated problems. Results for high-, moderate-, and low-assimilation subgroups (based on rating the level of assimilation of problems presented in the first 20 min of first sessions) of clients (N = 112) randomly assigned to time-limited cognitive-behavioral or psychodynamic-interpersonal treatment supported the first suggestion but not the second (clients with poorly assimilated problems did equally well in both treatments).

Paniagua, et al. suggested that the definition of a 'difficult' case in psychotherapy implies a relational definition involving the characteristics of the patient, the case, and the therapist. This study concerned this hypothesis with 44 graduate students in social work who received the Difficult Case Questionnaire representing examples of variables across each domain, e.g., motivation of the client, nature of the disorder, generic factors, and orientation of the therapist. The results were compared with the 1993 findings reported by Paniagua, et al., for a group of professionals in mental health practice. As in the earlier study, the present sample also agreed that, although all such domains are important in the formulation of that definition, their importance is not equal. Whereas professionals rated patient's, case's, and therapist's characteristics as the most important order of domains in that definition, students in this study agreed on the order of therapist's, patient's, and case's characteristics.

This study investigated, from the client's perspective, how the therapeutic process is associated with the retrieval of sexual abuse memories in psychotherapy. A qualitative analysis was applied to the transcripts of semistructured interviews of 11 adult women who identified themselves as victims of childhood sexual abuse and as retrieving memories of abuse during ongoing or past psychotherapy. Results are reported as themes or codes that represent participants' perspectives about the therapeutic process. Noteworthy codes are organized within the categories of (a) the therapeutic relationship, (b) therapeutic effects, (c) therapist characteristics, and (d) therapy techniques.

TOPIC. The use of Peplau's interpersonal nursing theory with people suffering from serious mental disorder. PURPOSE. To describe Peplau's theory and its application using a case study. SOURCE. Author's own [...]

The goal of the study was to develop a computer-aided system that is able to identify key moments in transcripts from psychoanalytic sessions and to provide an adequate theory of change. The term key moment refers to 1 or more sessions of a treatment or to segments of a session that are seen as clinically important and often considered to be a turning point or breakthrough and that mirror points of insight as they occur in the course of the psychotherapeutic process. It will be shown that patterns built of combinations of the content analysis variables 'emotion tone' and 'abstraction' allow for describing therapeutic cycles including key moments. The method is shown successfully for a single case and for a sample of improved and not improved patients.

Data from seven contexts (gender history, dichotomized bitterness, links between assertions and proofs, dramatizing facts, malpractice and other legal actions, therapists' own history of abuse, and therapists' experience of recovered memories) are presented and their implications explored. The data support the thesis that individuals, the profession, science, and society suffer when research findings, clinical interventions, and public policy are taken out of these seven contexts. Even otherwise reliable facts, theories, laws, and practices can become distorted, misleading, and, ultimately, harmful.

The debate over repressed memories of sexual abuse has been conducted in the popular press and the public imagination as well as in the professional literature of feminist psychotherapy, contemporary psychoanalysis and cognitive science. At issue are prescriptive questions concerning the status of recollection, subjectivity, and 'the real' in clinical and public life. Such questions are also at the center of interdisciplinary inquiry and reflect the post-modern theorizing in contemporary intellectual work. This paper will evaluate some of the conceptual issues at stake in this controversy. It is argued that consideration of the controversy itself, in addition to the problems to which it refers, has important implications for the clinical professions as well as for survivors of abuse. The apparent assessment of memory at the center of this debate is also being used to generate an evaluation of clinical work itself, and reflects efforts to justify regulating and limiting the scope of clinical practice.

Recent decades have seen a marked expansion in knowledge regarding human neurophysiology, and psychiatry is currently challenged with the task of integrating this information with a psychodynamic understanding of emotional life. In this paper we review portions of the relevant literature regarding the basic brain functions of affect, memory, and attachment, and we consider the implications of these data for integrated psychobiologic conceptualizations of emotional dysfunction and its treatment. In particular, data from these three areas of study point to the possibility that implicit memory of the early attachment relationship, communicated via the language of affect, is an enduring neural structure that influences both emotional self-regulation and behavior related to relatedness. Finally, we consider the implications of this proposition for the nature of psychotherapy, which from a psychobiologic view might be profitably conceptualized as a directed attachment relationship whose purpose is the revision of the implicit emotional memory of attachment.

This paper presents a behavior analytic understanding of the functional components of the therapeutic relationship. Whereas other models of understanding therapy have offered interpretations of the importance of the client-therapist alliance, few have specified mechanisms responsible for mediating change that have a foundation in experimental psychology. Consistent with the radical behaviorally based Functional Analytic Psychotherapy (FAP), we describe, using a contemporary understanding of verbal behavior, how the therapist establishes him or herself as a provider of social reinforcement in order to shape change using contingent and noncontingent responding. We propose a reason why a limited amount of client-therapist contact can produce large changes in behavior. The paper closes with a description of a research strategy for evaluating the proposed model of effecting client change as a function of the therapeutic relationship.

A case of a lesbian couple is presented in which one partner experienced early sexual abuse and the other a series of major losses (beginning with the death of her mother) in early childhood. The first partner developed an alcohol addiction and the second a high level of emotional lability and some practices of self-harm. Both partners developed dissociative patterns. The couple is now in a committed relationship and have continued in therapy for the last nine months, with sessions gradually becoming less frequent. The therapeutic work has included the 'externalization' of the problem(s), some individual work within the couple session using Eye Movement Desensitization and Reprocessing (EMDR), and a strong emphasis on the development of empathic skill through the technique of 'becoming' the other person. The case reveals the way in which a primary relationship often surfaces intense unresolved feelings and dysfunctional relationship practices, and also the way in which emotional commitment and a structure for the couple becoming therapeutic agents to each other allows for a deep level of healing. The couple comments on their relationship process and the therapeutic process as part of the article.

This special section has a dual focus. One is on psychotherapy change research. The other is to explicate an approach to develop a program of research that builds on 2 aspects of scientific discovery: decomposition of observed phenomena and localization of specific elements that may combine to produce a complex whole. These aspects are considered within an ordered framework of 8 steps in the development and testing of a model, moving from discovery to model construction, validation, and prediction of complex outcomes. Studies on psychotherapy change processes were selected, after a masked review, to represent different levels in developing a program of research. Although it is argued that the early steps of decomposition and localization are important when developing a program of research, current editorial practices in first-tier journals, including the Journal of Consulting and Clinical Psychology, typically consider this type of study to be too preliminary for a scientific archival journal. Should this practice be revisited?

A recently developed program for extensive inpatient grief therapy in groups, administered on a time-limited basis, is outlined, an illustrative case study is described, and empirical assessment of the program's efficacy is provided. During a 3-month stay in a Dutch Health Care Centre, a combined treatment program was offered that integrated behavior and art therapy [so-called Cross-Modality Grief Therapy, (CMGT)]. Assessment (levels of symptomatology on the General Health Questionnaire) was made at pretest, post-test, and follow-up and was compared with levels at comparable time points among participants in a more traditional program. Systematic advantages were found for CMGT. Discussion focuses on the identification of elements within CMGT that were responsible for its effectiveness.

The bestowal of the 1996 Leona Tyler Award to C.H. Patterson is a fitting culmination to 55 years of association with psychology. He began his long and fruitful career as a child psychologist, but has since dabbled in aviation psychology, clinical psychology, rehabilitation psychology and educational psychology. He traces the evolution of the idea that the essence of psychotherapy is love to the recognition that the preservation of life and civilization is dependent on love.

The crisis in positivist rationality has spawned three different theoretical alternative models of approaches used by human beings in constructing their realities. Social constructionism posits the idea that human reality is formed and has its being in discourse while critical realism, although not denying the role of language, emphasizes the implication of material-causal processes in other modes of construction that are independent of language use and the realities it creates. Finally, the humanist tradition focuses on the potentials of human consciousness. Based on interviews where clients detailed in their own words the influence of psychotherapy in their lives, it is argued that all three modes are incorporated in reality construction. A multimode perspective is therefore needed to develop an integrated model that systematically includes the different aspects of client experience.

This article proposes, within the context of discouraging findings from child psychotherapy literatures, 2 theory- and empirically based explanations for the emergent success of multisystemic therapy (MST) when implemented in community settings as well as for MST's favorable long-term effects on serious antisocial behavior in adolescents. First, MST may have demonstrated success in community settings because it explicitly bridges the gap between university-based psychotherapy studies and their community-based counterparts (J. R. Weisz & B. Weiss, 1993). Second, although MST is based on a social-ecological model of behavior, its favorable cross-setting and temporal outcomes may exemplify the successful use of several active behavioral generalization strategies.

The emphasis Carl Rogers placed on his personal experiences in developing his theory of psychotherapy prevented him from using the theories of other theorists, such as Karen Horney and Harry Stack Sullivan, whose works could have helped him. Rogers wanted to develop his theory independently, and his client-based psychotherapy is based on a similar concept. According to Rogers, his own experience took precedence over that of others and he wanted his patients to feel the same. However, in doing so, patients like Rogers himself would need more time to develop.

Practising psychologists and medicos often ignore patients of cancer and their families. Still, psychological intervention is a very significant part of the healing process and treatment. A certain amount of basic information regarding oncological treatment and terminology is a must for the psychologists. After learning the technical aspect and the required skills, the psychologists can establish emotional relationships and be of help in terms of treatment interventions for patients and their families.

Equine psychotherapy, first begun in Europe, is a fledgling therapeutic resourc for a very broad range of diagnoses. It is a powerfully effective tool in assisting clients who are fearful, anxious, depressed, angry, dissociative, or who have a variety of other emotional problems. Introducing therapeutic work with the horse to a client who is accustomed to conventional 'office therapy' is, in itself, a change. Work with horses breaks through the client's defensive barriers and requires the client to develop fresh insights and new perspectives from old relationship and behavioral patterns. Work with the horse requires cooperative affective and behavioral consistency in clients who have learned a habit of thinking one way, feeling otherwise, and behaving in a manner that may be totally unrelated to either. We, as therapists, may not discern this important dissonance in the office, but the horse seems to sense the incongruit and will display confusion until the client is internally consistent.

The life-altering personal experience of the author on her first three-day vision quest is interwoven in this article with the experiences of other women questers and the knowledge the author has gained as a leader of wilderness experiences and as a therapist with women questers. Five phases of any quest, o wilderness experience, are described using personal and anecdotal descriptions of each phase to offer both a subjective and objective understanding of the questing process. The five phases are preparation, severance, threshold, reincorporation, and implementation. The threshold phase, the time spent alone and fasting in the wilderness, is described in greater depth than the other phases. This is often the most memorable part of the questing experience. The final section of the paper offers thoughts on the lasting benefits of this type of wilderness experience. Included in this section are thoughts on why the awakenings from such experiences are life-altering for some and seemingly more transitory for others.

All models and theories of psychosocial psychotherapy have the common denominator of empowering the patient. The experience of mental disorder heightens the experience of inequality in relations, making the patient feel overwhelmed. Psychotherapists should redress this imbalance by empowering their patients. The formation of trust relationships gives the patient power in that they are causing someone to listen to their hardhips.