Faculty Bibliography

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

Studies involving patients with personality disorders (PD) have not focused on improvement of core aspects of the PD. This paper examines changes in quality of object relations, interpersonal problems, psychological mindedness, and personality traits in a sample of 156 patients with DSM-IV PD diagnoses being randomized to either manualized or non manualized dynamic psychotherapy. Effect sizes adjusted for symptomatic change and reliable change indices were calculated. We found that both treatments were equally effective at reducing personality pathology. Only in neuroticism did the non manualized group do better during the follow-up period. The largest improvement was found in quality of object relations. For the remaining variables only small and clinically insignificant magnitudes of change were found.

Professional psychology has increasingly moved toward evidence-based practice. However, instruments used to assess psychologists seeking licensure, such as the Examination for Professional Practice in Psychology (EPPP), have received relatively little empirical scrutiny. Therefore, the authors evaluated the available evidence in support of the EPPP's validity and current use as a core component of professional licensure. Although the EPPP has in many ways been extensively evaluated, there is a paucity of criterion, predictive, and incremental validity evidence available. Further, several aspects of the content validation studies were examined, and the authors question whether the EPPP, as currently constructed, can meet its stated goals. Given that the EPPP is a high-stakes examination and given the authors' best estimate (based on a sample of 16 states) that 35% of applicants fail the examination, it is recommended that the EPPP be more extensively evaluated. An outline of major decision points in this proposed evaluation process is provided, several suggestions for further research are proposed, and the field is encouraged to discuss these issues further.

Through the course of this paper we discuss several fundamental issues related to the intervention competence of psychologists. Following definitional clarification and proposals for more strictly distinguishing competence from adherence, we interpret Dreyfus and Dreyfus's [Dreyfus, H.L., & Dreyfus, S.E. (1986). Mind over machine: The power of human intuition and expertise in the age of the computer. New York: Free Press.] five stage theory of competence development (from novice to expert) within a strictly clinical framework. Existing methods of competence assessment are then evaluated, and we argue for the use of new and multiple assessment modalities. Next, we utilize the previous sections as a foundation to propose methods for training and evaluating competent psychologists. Lastly, we discuss several potential impediments to large scale competence assessment and education, such as the heterogeneity of therapeutic orientations and what could be termed a lack of transparency in clinical training.

The author discusses the evidence for six basic statements that many, but not all, psychotherapy researchers adhere to: (1) The therapeutic alliance has a causal role in outcome, (2) therapeutic techniques explain patients' outcome, (3) therapists determine outcome, (4) patients determine therapy outcome, (5) randomized controlled trials (RCTs) provide valuable data, (6) data from RCTs are almost worthless. These "truths" combine to form three core conflicts: Is psychotherapy about the alliance or techniques? Does the patient or therapist determine the outcome? Are RCTs a blessing or a curse? After showing that these statements oversimplify the research of the therapeutic process, the author recommends keeping both sides of the conflict in awareness and endorses a pluralistic methodological approach for the study of both efficacy and the mechanisms of psychotherapy.

The Multitheoretical List of Therapeutic Interventions (MULTI) assesses interventions from eight different psychotherapy orientations (behavioral, cognitive, dialectical-behavioral, interpersonal, person centered, psychodynamic, process-experiential, and common factors) and from the perspective of clients, therapists, and observers. The internal consistency for the subscales was moderate to high. Split-half reliability was moderate for clients and low to moderate for therapists and untrained observers. Interrater reliability for the subscales was low for untrained raters but moderate for psychotherapy-knowledgeable raters. A model of the MULTI subscales representing different psychotherapy orientations fit the data adequately but not parsimoniously in a confirmatory factor analysis. MULTI subscale levels successfully predicted sessions of different psychotherapy orientations. The MULTI seems to be a promising tool to investigate the interventions that occur in different psychotherapies.

This reprinted article originally appeared in Journal of Consulting and Clinical Psychology, 2000, Vol. 68, (No. 6), 1027-1032. (The following abstract of the original article appeared in record 2001-17092-008.) The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive-compulsive personality disorder who received supportive-expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome.