Life Is About Change: A Professional Memoir.

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

Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance.

OBJECTIVE: The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of clinical strategies to repair alliance ruptures. METHOD: This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Docherty, & Kahn 1997). In Phase I, 69 therapists submitted clinical situations describing alliance ruptures. In Phase II, 177 therapists generated responses to the situations, and clinical strategies underlying the responses were identified. In Phase III, 134 peer-nominated experts (a mean of 22.3 therapists per situation) rated the effectiveness of these clinical strategies. RESULTS: The experts reached consensus on the use of strategies that validated the client's experience and explored the rupture during the rupture session. Change-oriented interventions (e.g., changing interpersonal interactions; highlighting patterns of behavior, thought, or emotions) were generally rated as less effective to use during the rupture, but effective for use in future sessions. CONCLUSIONS: The findings are consistent with the growing literature on the value of using certain alliance-focused interventions during a rupture. The findings point to the importance of therapists' awareness of the state of the alliance so that they can identify when ruptures are occurring.

A Professional Journey Through Life.

In response to the request to write about those changes that have occurred in my professional outlook and practice that have come with age, I have recounted some of the experiences I have had that seem to have contributed to these changes. There are a couple of important themes that have run through my professional experiences as a therapist, supervisor, teacher, and researcher. One of the themes has to do with my psychotherapy orientation. The other involves the tension that I have experienced between research and practice. I begin by discussing each of these, and then go on to highlight some of the more general lessons learned over the years, including coming to be more myself as a therapist, developing a broader perspective on life, being more clinically integrative, and learning to be accepting of what therapy can and cannot do.

Research on psychotherapy integration: building on the past, looking to the future.

Integration has become an important and influential movement within psychotherapy practice, reflected by the fact that many treatment providers now identify as integrative. However, integration has not had as great an influence on psychotherapy research. The goal of this paper is to highlight the growing body of research on psychotherapy integration, and to identify future directions for research that may strengthen the integration movement as well as the field of psychotherapy as a whole. We first summarize the past 25 years of research on integration, with a focus on four approaches to integration: theoretical integration, technical eclectic, common factors, and assimilative integration. Next, we identify directions of research within these four areas that could strengthen and support integrative practice. We then propose ways in which the perspective of integrationists could contribute to psychotherapy research in the critical areas of harmful effects, therapist effects, practice-oriented research, and training. We end this paper by suggesting that a greater collaboration between integrationists and psychotherapy researchers will help to create a unified landscape of knowledge and action that will benefit all participants and advance the field.

A 21st Century Principle-Based Training Approach to Psychotherapy: A Contribution to the Momentum of Transtheoretical Work.

Background: Despite the finding that the majority of psychotherapists adopt a rather process-oriented and integrative stance, it is uncommon that psychotherapy trainings are transtheoretical and transdiagnostic. Considering principles of change that cut across different schools of therapy holds promise for developing truly research-informed psychotherapy trainings. Common principles of change may answer the question what should be trained. Another important question is how to train. In current psychotherapy training programs, transfer of theory into practice relies mainly on role-playing exercises and supervised practice, both of which have their limitations. Aims: A fantasy for the future would be the development, implementation, and evaluation of a complementary 21st century online principle-based and marker-led psychotherapy training: incorporating the concepts of deliberate practice as well as expert training, the huge potential of technologies, and considering the importance of (context) responsiveness. Conclusion: To illustrate this idea, we present a training that we are currently developing, an online Alliance-Focused Training.

Consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: A survey of clinicians and researchers.

Goldfried (1982) hypothesized that there are five transtheoretical principles of change that guide routine psychotherapy practice. This survey investigated if there is consensus on the perceived presence of these principles in the approaches of a professionally diverse pool of psychotherapy clinicians and researchers. One thousand nine hundred ninety-eight participants, aged 21-85 years (M = 50.4 years, SD = 15.59) and representing a wide variety of theoretical orientations, completed an online survey. For consensus to be indicated, 95% confidence intervals of mean agreement scores had to be above 4.0 (out of 5). Mean agreement levels in response to "the extent to which you agree that the following principles are present in your own approach to psychotherapy" indicated consensus for all five principles: (a) fostering hope, positive expectations, and motivation (M = 4.58; 95% CI [4.53, 4.62]); (b) facilitating the therapeutic alliance (M = 4.76; 95% CI [4.73, 4.80]); (c) increasing awareness and insight (M = 4.66; 95% CI [4.63, 4.70]); (d) encouraging corrective experiences (M = 4.44; 95% CI [4.39, 4.48]); (e) emphasizing ongoing reality testing (M = 4.15; 95% CI [4.09, 4.20]). These findings were unaffected by age, gender, working patterns, practice (clinician or researcher), and years of experience; however, consensus on the final two principles was not indicated for both psychodynamic and experiential psychotherapists. The demonstrated consensus surrounding the transtheoretical principles of change corresponds with their consistently yielded outcome associations in previous research. The combination of these evidence sources points to the importance of the principles in routine psychotherapy practice, which warrants further investigation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Revived call for consensus in the future of psychotherapy.

The emblem of success in psychotherapy research and practice has long been innovation. Although such ingenuity is commendable, it has nonetheless perpetuated fragmentation across the field. At least four decades ago, it was suggested that achieving consensus on what constitutes psychotherapy's theoretical, empirical, and practical 'core' might allow the discipline to evolve beyond its siloed state, as is reflective of mature science. Yet, division remains the rule versus exception, owing in large part to power struggles among disparate schools of therapy and quarrels over whether theory-specific or theory-common factors most account for therapeutic change. We outline here a vision for psychotherapy's future that is defined by consensus rather than disintegration. Namely, we reiterate the need for the field to invest in clinical strategies that transcend ostensibly incompatible theoretical models. We also argue that psychotherapy research should build on the growing evidence for such clinical strategies in an effort to establish core, evidence-based principles of therapeutic change. We then discuss how establishing consensus will require reconciliation among the mounting evidence for flexible, principle-informed practice with the current realities of training, dissemination, and implementation paradigms. Finally, we articulate ways in which practicing clinicians will serve a vital role in carrying out, and amending as needed, actionable efforts toward psychotherapy consensus.

Obtaining consensus in psychotherapy: What holds us back?

Although the field of psychotherapy has been in existence for well over a century, it nonetheless continues to be preparadigmatic, lacking a consensus or scientific core. Instead, it is characterized by a large and increasing number of different schools of thought. In addition to the varying ways in which psychotherapy has been conceptualized, there also exists a long-standing gap between psychotherapy research and how it is conducted in actual clinical practice. Finally, there also exists a tendency to place great emphasis on what is new, often rediscovering or reinventing past contributions. This article describes each of these impediments to obtaining consensus and offers some suggestions for what might be done to address them. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The gap between science and practice: A conversation.

The authors, friends, colleagues, and collaborators for almost 60 years engage in an informal discussion concerning the gap between science and practice. They identify some sources of the problem, some manifestations of it, and point the way to some possible solutions. The articles in this special section, because of their use of data collected in a naturalistic setting and the prominent role of clinicians, are viewed as one of many promising directions for the reconciliation of the activity of researchers and the needs of clinicians. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Extension of the rejection sensitivity construct to the interpersonal functioning of gay men.

On the basis of recent evidence suggesting that gay men are particularly likely to fear interpersonal rejection, the authors set out to extend the rejection sensitivity construct to the mental health concerns of gay men. After establishing a reliable and valid measure of the gay-related rejection sensitivity construct, the authors use this to test the mediating effect of internalized homophobia on the relationship between parental rejection of one's sexual orientation and sensitivity to future gay-related rejection. The present data support this mediational model and also establish rejection sensitivity's unique contribution to unassertive interpersonal behavior in the context of internalized homophobia and parental rejection. The authors conclude that gay-related rejection sensitivity is a useful construct for clinicians working with gay men given the impact that past gay-related rejection can have on their gay clients' present cognitive-affective-behavioral functioning. The authors discuss the possibility of revising rejection-prone schemas in clinical work with gay men. Future research is necessary to further examine the internal processing and interpersonal functioning of gay men by using existing constructs (or modifications of them) that are likely to be particularly relevant to the unique concerns of this population.

On the next generation of process research.

This set of articles offers examples of innovative and exciting trends in psychotherapy process research. We briefly review the state-of-the-art of psychotherapy research, highlighting some limitations of current approaches in the field and the pressing need to move beyond the current state of affairs. We note that the methods advocated and put to use by the authors in this issue are quite likely to lead the field in a more desirable direction. Specifically, these methods allow a more complex and contextual way to examine the process of change and relapse. Taken together, the methods proposed here come closer than previous research procedures to capturing the realities that clinicians face in their real-life interventions. For this reason, we hope that the future of process research will include more studies of this type.

What has psychotherapy inherited from Carl Rogers?

Rogers' classic article (see record 2007-14639-002) on the necessary and sufficient conditions for therapeutic change--now 50 years old--has made an indelible impact on the field. In his brief article, Rogers broke with the past, making a compelling case for the importance of subjecting our hypotheses about how therapy works to empirical test. Moreover, his emphasis on the importance of the therapy relationship is now routinely accepted as necessary, even if not sufficient for change to occur. Having moved beyond Rogers' necessary and sufficient conditions, the field of therapy now recognizes that as important as the therapy relationship might be, there are certain clinical problems that require the use of specific techniques to bring about change. Still, it is currently recognized that therapist acceptance is essential, that nondirective methods can be effective in improving client motivation, and perhaps most important, that the therapist needs to work toward the development of evidence-based interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Social anxiety in young gay men.

Based on the assumption that sexual minority individuals are particularly sensitive to the possible rejection of others, the present study examined the occurrence and correlates of social anxiety symptomatology in gay and heterosexual men. Eighty-seven heterosexual and 87 gay undergraduate men between the ages of 18 and 24 completed common measures of social anxiety, self-esteem, boyhood gender conformity, and a modified S-R Inventory of Anxiousness. Results reveal that gay men reported greater fear of negative evaluation and social interaction anxiety and lower self-esteem than heterosexual men. Gay men who are less open about their sexual orientation and those who are less comfortable with being gay were more likely to experience anxiety in social interactions. The modified S-R Inventory of Anxiousness was useful in revealing that relatively innocuous situations for heterosexual men can be anxiety-provoking for gay men. The hypothesis that gay men who were gender nonconforming as children would report a higher degree of social interaction anxiety was not supported. Results are discussed in terms of the socialization experiences of gay men and are explicated using a minority stress framework. Implications are offered for the treatment of social anxiety in this population.

Therapist qualities preferred by sexual-minority individuals.

Psychotherapy research concerning lesbian, gay, and bisexual (LGB) individuals has focused on matching clients on gender and sexual orientation, yet has not considered how factors such as therapeutic skill, presenting problem, and cohort membership may influence preference for therapists. This study was designed to identify those therapist qualities that sexual-minority individuals prefer and to determine how the presenting problem influences therapist choice. Forty-two nonheterosexual adults between 18 and 29 years old ranked 63 therapist characteristics from "Extremely Uncharacteristic" to "Extremely Characteristic" when seeking treatment for a problem in which their sexual orientation was salient and one in which it was not. The analyses of both conditions yielded clusters of items reflecting therapist characteristics that participants considered unfavorable, neutral, beneficial, and essential. Participants valued therapists who had LGB-specific knowledge as well as general therapeutic skills, whereas they indicated that they would avoid therapists who held heterocentric views. Application of these findings to clinical practice and future directions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Clinical Feedback About Empirically Supported Treatments for Obsessive-Compulsive Disorder.

Previous evidence for the treatment of obsessive-compulsive disorder (OCD) has been derived principally from randomized controlled trials. As such, evidence about the treatment of OCD has unilaterally flowed from researchers to clinicians. Despite often having decades of experience treating OCD, clinicians' feedback on their clinical observations in using these treatments has not been solicited. The current study contacted clinicians for their clinical observations on empirically supported treatments for OCD to identify commonly used cognitive-behavioral techniques and their limitations in their practices. One hundred eighty-one psychotherapists completed an online survey. The average participant practiced psychotherapy for 15 years, worked in private practice, held a doctorate, and treated an average of 25 clients with OCD in their lifetime. In regard to the most common techniques, behavioral strategies involving exposure to a feared outcome and prevention of a compulsive ritual were the most frequent group of interventions, followed by techniques that attempted to identify and challenge irrational thoughts. However, the majority of participants also reported incorporating mindfulness or acceptance-based methods. Based on therapists' reports, the most common barriers to the efficacy of cognitive-behavioral interventions included limited premorbid functioning, chaotic lifestyles, controlling and critical families, OCD symptom severity, OCD symptom chronicity, and comorbidities. This study provides insight into common practices and limitations in clinical practice to inform future clinically relevant treatment research.

Implications of RDoC for the research and practice of psychotherapy.

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

On the need for a new psychotherapy research paradigm: comment on Westen, Novotny, and Thompson-Brenner (2004).

Basic, process, and outcome research have the potential to inform clinical practice. However, as D. Westen, C. M. Novotny, and H. Thompson-Brenner observed in their timely analysis, the current dominant paradigm for psychotherapy outcome research--the randomized clinical trial--is not fulfilling this potential. The field's reliance on the medical model and manual-based interventions has contributed to the gap between research and clinical practice. Greater collaboration between practitioners and researchers, a focus on therapeutic principles rather than treatment packages, and systemic changes in how scholarly efforts are reinforced are needed to shift the current research paradigm.

Convergent validity of the Agnew Relationship Measure and the Working Alliance Inventory.

The convergent validity of the Agnew Relationship Measure (ARM) and the Working Alliance Inventory (WAI) was assessed in samples drawn from 2 comparative clinical trials of time-limited psychotherapies for depression. In 1 sample, clients (n = 18) and therapists (n = 4) completed self-report versions of both measures after every session (n = 198). In the other sample, clients (n = 39) and therapists (n = 6) completed the ARM, and observers subsequently rated selected audiotaped sessions (n = 78) using the WAI. In both samples, the ARM's core alliance scales (Bond, Partnership, and Confidence) were correlated with the WAI's scales (Bond, Tasks, and Goals) strongly when assessed within client and therapist perspectives and, with some qualifications, moderately when assessed between client, therapist, and observer perspectives, supporting the assumption that the ARM and the WAI measure some of the same core constructs.

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

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