Comparing the Process in Psychodynamic and Cb Therapies

7/28/2019 Comparing the Process in Psychodynamic and Cb Therapies

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J o u r n a l o f C o n s u l t i n g an d C l i n i c a l Psycholog '1993. V o l . 6 1 , N o . 2 , 3 0 6 - 3 1 6 C o p y r i g h t 1 9 9 3 h\ U K A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n I n c0022-(>06X/93/$3 .00

Comparing the Process in Psychodynamicand Cognitive-Behavioral Therapies

Enrico E. Jones and Steven M. PulosArchi v a l r ecords wer e us ed to c o m p a r e th e t h e r a p y p r o ce s s i n 30 br i e f p s y c h o d y n a m i c and 32cogni t ive-behaviora l the r ap i e s . V erba t im t ranscr ip t s of 186 t r ea tm ent s e s s ions wer e r a t ed wi t h th ePsycho the rapy Process Q-set , des igned to p rovide a s t andard l angu age for the de scr ip t ion of p ro-c e s s. R e s u l t s d e m o n s t ra t e d t h a t a l t h o u g h s om e f e a t u r e s w e r e co m m o n t o b o t h t r e a t m e n t s , t h e r ewere i m p o r t a n t differences . Cogni t ive-behaviora l the r apy p romoted cont ro l of n e g a t i v e affectt h r o u g h t h e u s e o f i n t e l l e c t a n d r a t io n a l i ty co m b i n e d w i t h v i g o r ou s e n co u r a g e m e n t , s u p p o r t , a n dr eas surance from the r ap i s t s . In psychodynamic p sychothe rap i e s , the r e was an e m p h a s i s on theevoca t ion of affec t , on b r i n g i n g t r o u b le s o m e f e e l ings in to awarenes s , and on i n t e g r a t i n g cu r r e n tdifficu l t ies w ith p r e v i o u s l i f e e x p e r i e n c e , u s i n g th e the r ap i s t -pa t i en t r e l a t ionsh ip as a ch a n g eagent . T h e c l i n i ca l t h e o r e t i c a l p re c e p t s u n d e r l y i n g p s y ch o d y n a m i c t r e a t m e n t s r e c e iv e d co n si d e r -able s u p p o r t . In cogni t ive-behaviora l the r ap i e s , the r e w as e v i d e n c e for the i m p o r t a n c e of deve lop-m e n t a l , a s o p p o s ed to r a t iona l i s t , in t e rve n t ion s t r a t eg i e s fo r t r e a tm e n t o u t c om e .

A t h e o r y of p sycho t he rap y l eads t he rap i s t s to cons i de r th ena t u re and et iology of thei r pa t i ent s ' di sorders in a part i cularway and point s toward certa in f o r m s of i n t e rven t i on o r t ech-nique . T he t echn i ca l p re s c r i p ti ons o f p sychodyn am i c and cog-ni t ive-behavioral therap ies are of t en cont radic tory. For exam-ple , p sychodynam i c t he rap i s t s a re w ary of the consequence o fus ing sugges t ion, whereas cogni t ive-behavioral the rap ies of t ensugges t specific in-sess ion exerc i ses or out-of-session act ivi t ies.Im p or t an t and sys t ema t i c di f f er ences such a s t hes e shou ld p re -s u m a b l y lead to an ident i f iab le di f f er ence in the ef fec t ivenessof t r ea t m en t s ; however , t h ey have no t .In t r ea t me n t s t ud ie s , r e s ea rchers have fai led t o demons t ra t esys temat ica l ly the di ffe ren t i a l effects of di ffe ren t t r e a tmen t s(Mi l l e r & B erman , 198 3 ; Smi t h , Glass, & M iller , 1980). Theap p a ren t p a radox of lack of di ffe ren t i a l effectiveness in con-t ras t to evide nt t echnical divers i ty (or outcom e equivalence co n-t ras t ed wi th content nonequivalence) has been widely noted(e.g., St i les , Shap i ro , & Ell iot t , 1986) . Most recent ly , th e r epor tof t h e N a t iona l I n s t i t u t e o f M en t a l Hea l t h T rea t men t o f De-pre s s io n Collaborat ive Research Program noted fe w differ-e n c e s a m o n g t h e ef fec t iveness of i n t e rp e r sona l p sycho t he rap y ,

Enr i co E . Jo n e s, D e p a r t m e n t of Psychology, Uni v er s i t y of C a l i forn i aat Berke l ey ; St even M . P u l os , D e p a r t m e n t of Psychology, Uni v er s i t y ofN o r t h e r n Colorado.This r e s ear ch w as suppor t ed b y N a t i o n a l I n s t i t u t e of Men tal Heal thResear ch Grant R01 MH 38348.Jan i c e D. Cu m m ing , Sarah Hal l , Les l ey A . Parke , Sandra Tunis , andothe r me m ber s of the Berke l ey Psychothe rapy Resear ch G r o u p contr ib-u t ed in m a n y w a ys to t h i s s tu d y . I n d i a F l e m i n g p r o v i de d co m m e n t s onseveral draf t s . Spec ia l thanks ar e ex t ended to George Silberschatz,John Cu r t i s , and Steven D . Hol lon for g r an t ing acces s to the i r dataa rch i v es .C o r r e s p o n d e n c e co n ce r n i n g t h i s a r t i c l e s h o u l d b e addressed toEnr i co E . Jo ne s , D e p a r t m e n t of Psychology , U niver s i ty of Ca l i fo rn i a ,Berkeley. Cal i fornia 94720.

cogni t ive-behavioral t he rap y , and an t i dep res san t m ed i ca t ionin t h e t r ea t m en t o f m a jo r dep res s ive d i so rde r. T he ab s ence o frea l d i f f e r en c es b e t ween t he t wo p sycho t he rap i e s was onceaga in cons t rue d as s u p p o r t for the i m p o r t a n c e of c o m m o n fa c -tors in di ffe ren t t y p e s of p sycho log i ca lly m ed i a t ed t r ea t me n t( E l k i n e t a l . , 1989).T h i s ha s l ed t o a t tem p t s t o iden t i fy a c o m m o n c o r e o f th e r a -p e u t i c process . It is poss ib le , fo r ins tance , tha t f ea tures sharedb y cogn i t i ve-b ehavi o ra l and p sychodynami c p sycho t he rap i e su n de r l i e di f f er ences in t echn i que an d t ha t t h es e commona l i t i e sare r e sp ons i b l e for the gene ra l equ i val ence in effectiveness. Al ine of r e s ea rch , once p op u la r b u t now ap p a ren t ly fading , tha ts t e m s from t h i s effort was on the " therape ut ic a l l i ance " (Fries-w yck e t al., 1986) . Most psychotherap i s t s have no t found th et h e rap e u t i c a l l iance cons t ruc t suffic ient fo r assessing th e effec-t iveness of t h e i r t e c h n i q u e s or for e x p l a i n i n g ho w pat i ent schange ; it loca te s t he com m on core at too high a level of ab-s t rac t ion.T h e ques t i on o f w h e t h e r th e effects o f t h e r a p y a re th e r e su l to f speci f ic i n t e rve n t i on s tra t eg i e s and t e c h n i q u e s or the resul tof f ac t o rs com m on t o t he va r ious tr ea t me n t ap p roaches hasf u n d a m e n t a l t h eore t ic a l imp or t as well as practical clinical im -pl ica t ions . Some researchers have considered t h e ab s ence o fdi f f er en t ia l t r e a t m e n t effects a failure to suppo r t , if not a re futa-t ion of , the c l i n i ca l t h eor i e s an d m o d e l s o f m e n t a l func t ion ingfrom w h i c h t h e y are der i ved . T h i s absence o f dif fe rences h asalso raised ques t i ons ab ou t t he l i m i t a t i ons o f con t ro l l ed c l i n i ca lt r ia l s i n exp la i n i ng how p a t i en t s change t h rough such i n t e rven -t ions (e.g., Pe rsons, 1991) . A l t h o u g h compara t ive o u tc o m e s t u d -ies can address ques t i ons o f efficacy, the p robat ive value of suchs tudies for the t r e a t m e n t s ' under ly i ng t heore t i ca l cons t ruc t s i si n di re c t a n d l im i te d . U n d e r s t a n d i n g w h a t p ro m o t e s th e r a p e u -t ic change r equ i re s m ore d i r ec t s t udy o f t r ea t men t p roces ses .The r e have been f ew com p ara t ive s t ud i e s o f the p sycho t he rap yprocess , and the se have b een conduc t ed p r i mar i ly to d e t e r m i n ewhether cogni t ive-behavioral therapy and in t erpersonal ther-

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C O M P A R I N G T H E R A P Y P R O C E SS E S 307apy for depression can be discriminated (DeRubeis, Hollon,Evans, & Bemis, 1982; Luborsky & DeRubeis, 1984). The con-tent d i f f e r e n ce s in such newer manual-guided treatments havebeen demonstrated to be both large and systematic. However,d i f f e r en c e s in therapist technique have not been directly asso-ciated with di f f e r en t i a l e f fec t iveness .

The present study was an attempt to determine what aspectsof the therapy process are di f f e r en t and what qualities are simi-lar in psychodynamic and cognitive-behavioral therapies. Theaim was to assess, more directly than is possible in comparativeoutcome studies, the validity of the clinical theories that con-stitute the foundation of these two approaches to psychologicalintervention. Two sets of archival recordsone of cognitive-behavioral treatments and one of brief psychodynamic treat-mentswere obtained f rom other investigators. The study,which is based on the archival data, has certain limitations:There was no random assignment to treatment condition; thepatient populations in the cognitive-behavioral and psychody-namic therapies varied in the kinds of diagnoses and problemsthey represented; half of the patients treated in cognitive-behav-ioral therapy also received pharmacotherapy; indeed, the twosamples were not even assessed on the same treatment outcomemeasures. This study does not, then, constitute a formal com-parative outcome s tudy . Instead, it is an attempt involving theuse of the same device, the Psychotherapy Process Q-set (Jones,1985) , to describe processes in both cognitive-behavioral andpsychodynamic therapies and to iden t i fy which kinds of pro-cesses lead to patient improvement in these therapies in what-ever manner patient change was measured.

MethodPsychodynamic Therapy

Patient sample. The sam pl e of p sychodynam ic tr ea tme nt s was ob-ta ined from the Mou nt Zion Psychothe rapy Resear ch Group in SanFrancisco. The archive contained records for 38 cases and includedpr e- and pos t the r apy evalua t ions ob ta ined from pat i en t s , the r ap i s t s ,and c l in ica l evalua tor s , as we l l as compl e t e audio tape r ecords of a l lt r ea tm ent s e s s ions. Four cases could not be used for reasons of confi-dent ial i ty , 2 pa t ien t s t e rm ina t ed the r apy af t e r five or s ix sessions, andin tw o cases insuff icient as s es sment data were acqui r ed , l eaving a totalN of 30 (20 f ema le , 10 male) pa t i en t s in the s tudy sampl e . Approxi -mate ly ha l f of the s am pl e were r e f e r r ed by men ta l hea l th p rof es s ional sor phys ic ians ; th e other hal f were sel f-refer red. Patients were assessedt h r o u g h both an in take in t e rv i ew and p sycholog ica l s cr een ing tests.A ll pat i en t s wer e accep t ed in to th e s tudy if, at the t i m e of in take , (a )th ey had a h i s tory of m e a n i n g f u l interpe rsonal relat ionships; (b) the ydid no t m eet exclus ion cr i ter ia (i .e . , evidence of psychosis , organic im -p a i r m e n t , m e n t a l deficiency, s e r ious subs tance abuse or su ic ida l po-t ent ial) ; and (c) t was agreed by an independent evalua tor an d a n o t h e rc l in i c i an tha t the sub jec t was in need of t r ea tment and could po ten-t ia l ly benef i t from a cour s e of b r i e f the r apy . The m ean age of the s am -ple was 50 years (range, 20-81 year s ). One pa t i en t had a t l eas t someh igh s chool educa t ion , 5 pa t i en t s had comp l e t ed h igh s chool, 5 pa t i en t shad some co l l ege , 6 pa t i en t s had compl e t ed co l l ege , 8 pa t i en t s hadsome graduate school, and 5 patientshad completed doctoral degrees.Therapists and treatment. The 15 the r ap i s t s in the s tudy consideredth e p s y ch o d y n a m i c m o d e l to be the i r p r im ary theor e t i ca l or i en ta t ion .Five the r ap i s t s t r ea t ed 3 pa t i en t s each , f ive t rea t ed 2 pa t i en t s each , andanoth e r f ive t rea t ed 1 each ( to tal N= 30).Eight of the the r ap i s t s wer epsych ia t r i s t s , 6 were cl inical psychologis ts , and 1 was a psych ia t r i csoc ia l worker ; 13 w e r e m a l e and 2 were f ema le . T h e y had an average of

6 year s of p r iva t e p r ac ti ce exper i ence ( r ange , 1-19 years); all had re-ce ived som e spec ia lized t r a in ing in b r i e f p sychodynam ic the r apy . Theaverage treatm ent leng th was 15.8 sess ions .Assessment of outcome. Pat i en t ass es sment s wer e ob ta ined a t ini-t ial evaluat ion and at t e rmina t ion . Patients compl e t ed th e SymptomDis t re s s C heckl i s tRevis ed (SCL-90-R; Derogati s , Lipm an , R ick-els, U h l e n h u t h , & C o v i , 1974), a se l f -r epor t symp tom inventory con-s tructed to assess psycholog ica l an d symptom s ta tus . Therap i s t s an dcl in ica l evalua tor s compl e t ed the Br i e f Psych ia t r i c Rat ing Scal e(BPRS; Overal l & G o r h a m , 1962), which y i e lds a 0- to 96-poin t symp -tom score . A t the r ap y t e rm inat ion , pa t ien t s , the r ap i s t s , and e valuatorsal l co m p l e t e d an Overa l l Change Rat ing (OCR) , a 9-point rat ing scaler ang ing from very much worse (1 ) to very much improved (9).

Cognitive-Behavioral TherapyPatient sample. The data fo r th e cogni t ive-behaviora l the r apy sam -ple were col lected as p a r t of a s tudy to compar e the effec t iveness ofcogni t ive-behaviora l the r apy an d t r i cycl i c pharmacothe rapy , a loneand in com binat ion , in the t r ea tme nt of un ipol ar dep r es sion (Hol lon e tal. , 1989). The data se t p e r t i n e n t to the present s tudy included treat-m ent r ecords of 32 pa t i en t s who com pl e ted t r ea tment in one of the twopsychothe rapy condi t ions and conta ined as s es sment da ta ob ta inedfrom the pa t i en t s themse lves and from cl inical evaluators as well asaudio r eco rdings of the r apy s es s ions .The p a t i e n t s a m p l e m e t the fol lowing cr i ter ia a t in take evalua t ion: (a )a def ini te diagnos i s of ma jor dep r es s ive d i sorde r on the Resear chDiagnos t i c Cr i t e r i a ( R D C ; Spitzer , E ndico t t , & Robins , 1979); (b) ascore of &20 on the Beck Depr es s ion Inventory (BDI; Beck, Ward ,Mende l son , Mock, & Erbaugh , 1961) ; and (c) a score of > 1 4 on the17-item vers ion of the Ham i l ton Rat ing Scale fo r Depres s ion (HRSD;H a m i l t o n , 1967). Exclus ion cr i t e r ia r e l a t ing to d iagnoses , drug depe n-dency, and s ever e su ic ida l p r eoccupat ions wer e a lso app l i ed . Pa t i en tsw ho droppe d out wer e r ep l aced un t i l a to ta l of 16 pa ti en t s pe r g roupco m p l e t e d th e t reatm ent protocol. Hol lon et a l . (1989) repor ted thatthe groups d id no t d i f f e r s igni f icant ly with r e spec t to dropout rates.

The f ina l s amp l e cons i st ed of 25 f ema le and 7 mal e pa t i en t s ; the m eanag e of the s ampl e was 33.8 years , wi t h a s tandard deviat ion of 10.6 .Thr ee pa t i en t s had some h igh school educa t ion , 1 1 had compl e t ed h ighschool , 13 had som e co l l ege , 3 had com pl e t ed co l lege , and 2 had gradu-a t e or p rof es s ional t r a in ing .Therapists an d treatments. A cl in ica l p sycholog is t an d t h r e e c l i n i -cal social workers (3 m a l e , 1 f ema le) conducted th e t r ea tment s . A llunderwe nt 6 to 14 m onths of t r a in ing in cogni t ive-behaviora l the r apy ,and pos t t r a in ing supe rvi s ion s e s s ions wer e he ld once or tw ice weeklyt h r o u g h o u t the s tudy. Each of the fou r therapis ts t reated 4 pat ients ineach of the two the r apy groups . Pa t i en t s in both groups wer e s een for am a x i m u m of twen ty 50-m in sess ions over a 12-week per iod . The s tudyprotocol cal led for 2 sessions p e r week over the f i rst 4 weeks , e i the r 1 or2 sess ions p e r week over th e m i d d l e 4 weeks , and 1 sess ion p e r w e e kover the l as t 4 weeks . The average l eng th of t r ea tm ent was 14.4 ses-s ions . Pa t ien t s in the com bined t r ea tm ent g roup a l so me t weekly for 20to 50 m in with a psychiatr is t . These sess ions focused o n p h a r m a co t h e r -ap y m a n a g e m e n t a n d i n c l u d e d in f o r m a t i o n a b o u t t h e d o s e a n d p o s s i-b le side effec ts o f i m i p r a m i n e hydrochlor ide .Assessment of outcome. Pat ien t as s es sment s wer e ob ta ined beforethe f i rs t the r apy s ess ion and aga in a t pos t t r ea tm ent . Pa t i en t s com-pleted the BDI, a 21-i tem sel f-repor t inven tory des igned to assess nu-m e r o u s aspectsof sy n d r o m e depression including affective, cognitive,an d phys io log ic com ponent s (Bec k et a l , 1961) ; th e Depress ion Scale(Scale 2 ) of the M inne so ta Mul t iphas ic Pe r sonal i ty I nven to ry ( M M P I -D ; Hathaway & McKi nley , 1983); and the A utom at i c Thought s Ques-t ionnai r e (ATQ; Hol lon & K endal l , 1980), a 3 0 -i te m i n s t r u m e n t t h a tm easur es sub jec ts ' hab i tua l nega t ive thought s .Two cl in ic ian-r a t ed m easur es of dep res s ion w er e ra t ed by indep en-


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308 E N R I C O E . J O N E S A N D S T E V E N M . P U L O Sd e n t e v a l u a t or s w h o w e r e b l i n d t o t r e a t m e n t . T h e H a m i l t o n R a t i n gSca le fo r Depre ss ion (HRSD ; Ham i l ton , 1967) asse sse s se ve r i t y o f de -pre ss ive sym ptom s inc lud ing mood , gu i l t , su i c ida l i dea t ion , s l e ep d is -tu rbance s , and so fo r th ; th e pa t i en t ' s symptoms ove r th e p a s t w e e k arerated on e i t h e r a 3- or a 5-point scale ( to tal range , 0-50). The secondm e a s u r e , th e Rask in Dep re ss ion Sca le (RDS; Rask in , Schu l t e rbrand t ,Rea t i g , & McKeon , 1970), consists of 5-point rat ing scales on each ofthree separate aspects of depre ss ion , and scores range from 3-15 . Table1 prov ide s a s u m m a r y of the two data se ts .T he Psychotherapy Process Q-Set

T he 100-item Psycho the rapy P roce ss Q-set fu r n i s he s a language andra t ing procedure for the c o m p r e h e n s iv e d e s c r i p t i o n , in c l in i ca l ly r e le -vant t e r m s , of the t h e rap i s t -pa t i en t i n t e rac t ion in a fo rm su i t ab le fo rquan t i t a t ive com par i son and ana ly s i s . The in s t rum en t i s de s igned tobe appl i ed to an audio taped or video taped record or transcrip t of as ingle t r e a tm en t hou r a s t h e un i t o f obse rva t ion . U s ing th e psyc ho the r-apy ho ur i n i t s en t i r e ty has t h e advan tage o f a l lowi ng c l in i ca l judge s t os tudy the m a t e r i a l fo r c o n f i r m a t i o n o f a l t e rna t ive concep tua l i za t ionsand to a sse ss t h e g radua l ly unfo ld ing m ean ing o f even t s . A cod ingm a n u a l ( J o ne s , 1985) de ta i l s i n s t ruc t ions fo r Q-sort ing and prov ide sthe Q- i t ems and th e i r de f in i t i ons , a long wi th ope ra t iona l exam ple s t om in im ize po t en ti a lly va ry ing in te rpr e ta t ions of the i t ems.A f t e r s tudy ing th e r e co rd o f a t h e rap y hour , c l i n i ca l judge s p r o c e edt o t h e o rde r ing o f t h e 100 i t em s , e ach pr in t ed sep a ra te ly on ca rds t op e r m i t e as y a r r a n g e m e n t a n d r e a r r a n g e m e n t . T h e i te m s a re s o rt e d i n ton i n e pi l e s rang ing on a con t inuum f rom leas t cha rac t e r i s ti c (Ca tegory1 ) to m ost charac t e r i s t i c (Ca t egory 9 ), wi th th e m idd le p i l e (Ca t egory 5)u s e d fo r i t ems deemed e i t h e r neu t ra l o r i r r e l evan t fo r t h e pa r t i cu la rhour be ing ra t ed . The n u m b e r of ca rds so r ted into each pi l e (rangingfrom 5 at t h e ex t rem es to 18 in t h e m idd le o r neu t ra l ca t egory ) con-f o r m s t o a n o r m a l d i s t r i b u t i o n , r e q u i r i n g j u d g e s t o m a k e m u l t i p l eev a lua t i ons am ong i t em s and th e reby avo id e i t h e r nega t ive o r pos i t ivehalo effects, an d a t t enua t ing th e i n f l u e n ce o f r e sponse se t s (Block ,1 9 6 1 / 1 9 78) . The in t e r ra t e r r e l i ab i l i ty fo r t h e P sycho the rap y P roce ssQ-set has been cons i s t en t ly sa t i s fac to ry ac ross a var i e ty o f s tud i e s an dt rea tmen t sample s , w i th Pea rson p r o d u c t - m o m e n t corre lat ions rang-

ing f rom .83 to .89 for 2 raters an d from .89 to .92 for 3 to 10 raters( Jones , H a l l , & Parke , 1991) .In a test of d i s c r i m i n a n t val id i ty, a v ideo tape o f t h re e t h e rapy se s-s ions , conduc t ed w i t h t h e same pa t i en t by we l l -known propone n t s o ft h e i r r e s p e c ti v e t r e a t m e n t f o r m s ( A l b e r t Ell is , Fri tz Perls , and CarlRogers) , were rated by 10 t h e r a p i s t s who repre sen t ed a var i e ty of theo-r e t i c a l or i en t a t ions and a range o f expe r i ence . Fifty-two Q-items differ-en t i a t ed r a t i o n a l - e m o t i v e from ges t a l t t h e rapy , and 38 i t e m s d i f f e r e n -t i a t ed c l i en t - cen t e red th e rapy from ges t a l t t h e rapy . The 10 i t ems tha twe re de s igna t ed m os t an d l e a s t cha rac t e r i s t i c fo r each form o f t h e rapywere t h en pre sen t ed to ano the r g roup o f f ive t h e rap i s t s f ami l i a r w i tht h e s e t r e a tm e n t m o d a l it i e s , w ho successful ly m a t c h e d (p < .001) these ts o f Q-i t ems wi th th e t y p e of t h e r a p y from w h i c h t h e y h ad b e e nde r ived . Th i s back t rans la t i on o f t h e Q-se t i nd i ca t e s t ha t t h e i n s t ru -m e n t d i f f e r e n t i a t e d t y p e s o f t h e r a p y n ot only in t e r m s o f a l ar g e n u m -be r o f s ig n i f i can t d i f f e r e n ce s bu t a l so in a ma nne r t ha t accu ra t e ly cap-tu red th e nature of the var ious th eo re t ica l o r ien ta t ions that were repre-s e n t e d . A se r i e s o f s t u d i e s h as b e e n c o n d u c t e d t h a t d e m o n s t r a t e th ei n s t r u m e n t ' s capac i ty to i d en t i fy process corre lates o f o u t c o m e in d i f -f e r e n t p a t i e n t p o p u l a t i o n s an d w i t h d i f f e r e n t i n d i c e s of p a t i e n t im -p r o v e m e n t ( J o ne s e t al.. 1 9 9 1 ) .T he re lat ively l a rge num be r o f i t em s in t h e Q-se t i nc re ase s t h e poss i -b i l i t y o f m a k i n g a T y p e I error. Th e r e is an i n h e r e n t t rade-off b e t w e e nthe levels of Type I and Type 11 errors. In an exploratory study involvingda ta d i f f i c u l t t o ob t a i n , i t s e e m s scient if ical ly st rategic to l e s sen th el i k e l i h o o d o f T y p e I I e r ro rs ra the r t han ove rpro t e c t aga ins t Type Ie r ro rs . I n a re la t ive ly o p e n i n q u i ry , th e r e cogn i t i on o f pa t t e rns , cons i s -t enc i e s , and covar i a t i ons by t ra ined c l in i ca l obse rve rs u s ing th e broads e t of v a r i a b l e s r e p r e s e n t e d in the Q-i t ems a l lows for the d i scove ry o fi m p o r t a n t p h e n o m e n a a n d t h e r e l a t i o n s b e t w e e n t h e m .Q-ratings for the present study were c o m p l e t ed by a poo l of 10judge s , r e s e a r c h -o r i e n te d c l i n i c i a n s , an d g r a d u a te s t u d e n t s in c l in ica lpsychology, w ho r e c e i ve d t r a i n i n g i n t he a p p l i c a t i o n of t he Q-tech-n i q u e . T he j u d g e s r e p r e s e n t e d a range o f t h eo re t i ca l pe r spec t ive s , in -c lud i ng p s y c h o d y n a m i c and cogn i t ive -behav io ra l , a l t houg h mos t we reec l ec t i c in t h e i r c l in ica l o r i e n t a t i o n s . T h e v e r b a t i m t r a n s c r i p t s o fH o u r s 1 , 5, and 1 4 of each case ( N of t r e a t m e n t s e s s i o ns = 186) werecom ple t e ly random ized , and indepe nden t Q-ra t ings we re made by two

Table 1Arch iva l Data Sets

Samp le charac te r i s ti c C og n itive -b e havio ra l th e rap y sam ple P s yc h od yn am ic th e rap y s am pleNo . o f pa t i en t sGende r and e thn i c i t yA geDi agnos i sExclusion cri te r ia

Inc lus i on criteriaThe rap i s t s and t ra in ingAv erage no. of sessionsO u t c o m e m e a s u r e sT r e a t m e n t o u t c o m e effectsizeClin ical ly s ignif icantchange 3

16 in C/B t h e rapy a lone , an d 16 in C/B t h e r a p yplus d rug26 F , 6 M; 88% Whi t eM = 33.8 years; range, 18-62Depressive disorderDiagnosi s o f sch izophren ia , o rgan i c im pa i rm en t ,m en ta l de f i c i ency , a lcoho l ism , su i c ide r i skBDI score > 20H RSD-17 score > 141 psychologist , 3 social workers; special t ra ining& supervision in cogn i t ive t h e rapy14.4BDI, H R SD - 1 7 , ATQ, RDS, M M P I - D. 6 6 on compos i t e measu reBDI: 0, 25; H R S D - 17 : 8, 31; RDS:M M P I - : 0 , 10; A TQ : 4, 25

3020 F, 10 M; 100% W h i t eM = 50 years; range , 20-81Range of "neurot ic disorders"A p p r o x i m a t e l y t h e s a m eHistory of m e a n i n g f u l in terpersonal re lat ionships;

cou ld b ene f i t from brief psychotherapy6 psychologists , 1 social worker , 8 psychiatr ists;some t ra in ing in br ie f t h e rapy15.8SCL-90-R, BPRS.77 on GSI of SCL-90-R, .59 on BPRSSCL-90-R: 5, 18 b

Note. C/B = cogn i t ive -behav io ra l ; F = fem a le ; M = m a le ; BDI = Beck Depress ion I nven to ry ; H R S D - 1 7 = Ham i l ton Ra t ing Sca le fo r Depre ss ion ;A T Q = Automat i c Though t s Ques t ionna i re ; RDS = Raskin Depression Scale; MMP I-Z) = Minneso ta Mul t i phas i c Pe rsona l it y I nve n to ry Depre s-sion scale ; SCL-90-R = Symptom Dis t r e ss Check l i s t -Rev ised ; GSI = General Severity In dex; BPRS = Brief Psychiatr ic Rat ing Scale .a Nu m be r o f subjec t s i n t h e func t io na l range ( Jacobson & Truax , 1 991) on each o u t c o m e i ndex at p re t r e a tme n t and a t p o s t t r e a t m en t . b C h a n g erating, 86 % improved .


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C O M P A R I N G T H E R A P Y P R O C E S S E S 309judges who wer e b l ind to re l iabi l i ty checks ; when agr eem ent was be low.50, a third rater was added. The f ir s t hour was selected to ident i fyini t ia l aspects of the the r apy process , such as the f o r m a t i o n of a the r a-peutic alliance, that m ig h t be predictive of outcome. The fifth hourwas chosen to repl icate the des ign of two p r evious s tudie s ( Jones , Cum -m i n g , & Horowitz , 1988; Jones , K r u p n i c k , & K er ig , 1987). The 14thh o u r was s e lec t ed to cap tur e the end phase of tr ea tm ent a t a po in twhere the hou r would not be dom inated by t e rm inat ion i ssues; anaddi t ional p r ac t ica l consideration w as tha t s o m e pa t i en ts did not c o m -plete th e f u l l 16 sessions. Inter rater rel iabi l i ty was calculated by us ingthe Pear son p r o du c t - m o m e n t correlat ion coeff icient .

ResultsThe resu l t s are presen ted in the following sequence: first ,data on t re a tm en t effectiveness in the two t reatme nt group s arediscussed separate ly; ou tcom e be tween the two groups couldnot be com par ed d i re c t ly because th e data sets had no o u t c o m emeasu r e s in c o m m o n , as well as for o ther des ign reasons. Thisis followed by an analysis of the Q data com par ing the the rapyprocess in the two t reatm ent group s. Finally , the associat ion

be tween p roce s s and ou t com e i s exam ined .Treatment Outcome: E f f e c t Size a nd Clinical Significance

Patient change in psychodynamic therapies. Asse s smen t sfrom pat ien ts , therapis t s , and independent cl in ical evaluatorson the OCR showed an ave rage r a te o f pa t i en t im provem en tfrom pre- to post therapy of 86% (alpha = .71): change rat ingswere 83%, 97%, and 78% from pat ien ts , therapis t s , an d evalua-tors, respectively. The s t andard ized mean dif fe rence effect sizecoefficient (o r d) was calculated for the SCL-90-R an d BPRSscores pre- an d pos t t r e a tmen t . Effect s izes were m oderate : d =.77 for the SCL-90-R's General Sever i ty Inde x (o r GSI, whichreflects average intensity of s y m p t o m s e n d o r s e d) and .59 for theBPRS total scores.Clin ical s ign i f icance of pat ien t change was de f in ed as in Ja-cobson and Truax's (1991) s tudy: A pat ien t achieves a p ost tes ts co re on an ou t come m easu r e t ha t i s m o re l i k e ly t o be long inth e func t iona l t h a n th e dysfunct ional populat ion . Cutoff scoreswere calculated using th e m e a n s an d s tandard deviat ions de -rived from norm at ive da ta fo r func t iona l an d dysfunc t iona lsamp le s ; i t cou ld t hen be d e t e rm ined whe the r a pa t i en t crossedthis cutoff po in t in the direct ion of the norm at ive func t iona lsamp le from pretest to posttest. Est imates of clinically signifi-cant pat ien t change , presen ted in Table 1 , were for the m o s t p a rtreliable. These ou tcom e da t a a r e r epo r ted m ore fully e lsewhere(Jones, Parke, & Pulos, 1992).Patient change in cognitive-behavioral therapies. Out c om edata for the cogni t ive-behavioral therapy sample are repor tedin detai l by Hollon e t al . (1989). Our analysis of these datacorroborated the resu l ts repor ted the re , dem onst rat ing no s ig-nificant d ifferences i n ou t com e be tween patients t reated withcogni t ive-behavioral therapy alone and those t reated wi th cog-nit ive-behavioral t he r apy p lu s an t id ep r e s san t s on the var iousou t com e m easu r e s (a ll ps > .05). Effect sizes (d ) on a compos i t emeasure of the four outcome scales (BDI, HRSD, RDS, an dM M P I - D ) were m ode ra te an d c o m p a r a b l e in size: d = . 6 6 f o rcogni t ive-behavioral therap y plus an t idepressant m edicat ionand .58 for cogni t ive-behavioral therapy alone (Hollon e t al.,1989). In the absence of important diffe rences in outcome, th e

tw o s a m p l e s w e r e c o m b i ne d for all subsequent analyses (n = 32).Es t ima t e s of clinically significant pa t i en t change on several out-c o m e i n d ic e s ar e presen ted in Table 1 . A large percen tage ofpatients demonstrated reliable , clinically significant change onal l ou tcome measu r e s excep t th e M M P I- D (only 10 of 32).Q-Descr iptors of the Therapy ProcessThe analysis of the process data w as conducted in two s tages ,b eg i nn i ng wi th iden t i fy ing the most and leas t characte r i s t icQ-items fo r each t re a tm en t m odal it y . Thi s was followed by ananalysis of dif fe rences in the therapy process in cognitive andpsychodynamic t r e a tmen t s . Average in te r rate r reliabili ty for Q-sorts of therap y sess ions fo r bo th tr e a tm en t s (N = 186) ach i evedan r = .84. To iden t i fy th e process descr ip tors that m ost s t ronglycharacte r ized each t reatm ent , 100 i tem m eans we r e ca lcu la t edfrom th e i nd iv idua l Q -i tem p laceme n t s at Hours 1 , 5, and 14.The Q-item s were rank-ordered , and the 10 m ost and leas t char-acte r is t ic Q-i tems were iden t i f ied . These Q -i tem m eans rangedfrom a high of 7.96 to a low of 1.54 (see Tables 2 and 3) on the9-poin t Q-dis t r ibu t ion . A s t rategy of organiz ing i t ems acco rd -in g to m e a n i n g was chosen over a s tat i s t ical or di rect ional or -der i ng of i t ems so t ha t t he r e su lt s m igh t l end them se lve s m orereadi ly to cl in ical in te rpre tat ion . The Q-item n u m b e r s m e n -t ioned later refer to the i t e m s in Table s 1-5; th e word reversed ( T )indicates that the var iable required reflection to be or ien tedcomparab ly in the narrat ive .Psychodynamic therapy: Most and least characteristic Q-items. In gene ra l , t he se brief t r e a tme n t s we r e c harac te r i zed b yan e m p h a s i s on pat ien ts ' curren t life situation (Q-set I tem 69; Q69); however , pat ien ts ' fee l ings and percept ions were alsol inked to pas t situations an d behavior (Q 92). These patients asa g roup we re sad and depressed (Q 94) . St i l l , the y tended not tohave difficulty b e g i n n i n g th e h o u r (Q 25), an d t hey we r e notpassive in in i t ia t ing topics (Q 15, r); t he se f indings are consis-tent with th e fact tha t fe w s i lence s occu r r ed du r ing th e sessions(Q 12, r). The conten t in these hours consis ted of significanti ssues brought up by the pat ien t (Q 88) , including in te rpersonalre lat ionships (Q 63) and discuss ions of se l f- image (Q 35). Thetherapis ts in these t reatm ents were characte r i s t ical ly accept ingan d n o n j u d g m e n t a l (Q 18). They em phas ized p a t ien t s ' feel ings(Q 8 1 ) , clarified c o m m e n t s (Q 65) , an d ident i f ied r e cu r r en tthem es in pat ien ts ' expe r ience s (Q 62) . Therap is t s ' in te rve n-t ions were not general ly des igned to shore up o r s t rengthenpat ien ts ' defense s or to suppr e s s t roub le som e thought s and feel-ings (Q 89, r). Pat ien ts readi ly unders too d (Q 5, r) and accepted(Q 42, r) t he r ap i s t s ' com m en t s , po ss ib ly because i n t e rven t ion swere no t tactless (Q 77, r) or conde scend ing (Q 51 , r). Overall,t he r ap i s t s we r e charac t e r i zed by judge s as responsive an d affec-tively involved rather than d is tan t and aloof in m a n n e r (Q 9),an d pa t i en ts appear ed to feel unde r s tood (Q 14, r; see Jones e tal., 1992, for a m ore com ple te d iscuss ion) .Cognitive-behavioral therapy: Most and least characteristic Q-i tems. First, Q-sorts for the 16 pat ien ts who had been t reatedwith cogni t ive-behavioral therap y and an t id ep r e s san t me d i ca-t ion were com pared wi th those of the 16 pat ien ts who had be ent reated with cogni t ive-behavioral the rapy alone . Fewer i t em sd i s t i ngu i shed t he se two groups t han wou ld be expec t ed bychance (n = 94 i t ems at p > .05). C orrelations of Q-ratings fo rt h e two t r e a t m en t condit ions also demonst rated a high degr e e


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310 E N R I C O E. J O N E S A N D S T E V E N M . P U L O STable 2Rank Ordering ofQ-Items for Patients i n P sychod ynamic Therapy

PQS i t em and no. M10 Least charac t e r is t i c i t em s

Q 15. P does no t ini t ia te topics; i s passive .Q 25. P has d i f f i c u l t y beg inn ing th e h o u r .T is dis tant , aloof.P does no t feel understood by T.P has d i f f i c u l t y under s tanding T 's c o m m e n t s .Q 89. T acts to s t r eng then defenses.Q 12. Silences occur dur ing the h o u r .Q 51 . T condescends to or patronizes P.Q 77. T is tactless.Q 42. P rejects T's comments and obse rva t ions .

Q 9.Q 14.Q 5.

1.882.092.422.432.462.592.652.652.692.70

10 Most characteristic i t em sQ 69. P 's current or recent l i f e si tuat ion is e m p h a s i z e d . 7.60Q 63 . P ' s in t e rpe r sonal r e la t i onsh ips ar e a m a j o r t h e m e . 7.16Q 62. T ident i f i es a r ecur r en t t h e m e in P 's exper i ence or conduc t . 6.98Q 65. T clarifies, res tates , or rephrases P 's c o m m u n i c a t i o n . 6 .91Q 88. P br ings up significant issues and mate r ia l . 6.87Q 35. Self-image is a focus of discuss ion. 6.81Q 92. P's feel ings and perceptions are l i nk ed to the past . 6.75Q 8 1 . T emphas izes P 's feelings in order to h e l p h i m / h e r e x p e r ie n c e t h e m m o r e deeply . 6.57Q 94. P feels sad or depressed. 6.41Q 18. T conveys a sense of n o n j u d g m e n t a l accep tance . 6.40Note. Average i tem m e a n s ( H o u r s 1 ,5 , an d 14). T he n u m b e r of tr e a t m e n t h o u r s = 90. P Q S = Psychothe r -ap y Process Q-set; T = t h e r a p i s t ; P = pat i en t .

of s i m i l a r i t y , w i th correlations of . 9 6 f o r Hour 1,.95 fo r Hour 5,and .92 fo r Hour 14 . Q-data fo r cognitive-behavioral therapyalone as well as with antidepressant medication were subse-q u e n t l y combined for a l l f u r t h e r analyses.I n cognitive-behavioral therapy, there was much discussionof ideational themes, beliefs, or constructs used to appraise thesel f , others, or the world (Q 30); patients' attitudes or percep-tions of self were a concomitant focus (Q 35). Current and re-cent l i fe situations (rather than the past) were emphasized (Q69), and there was talk of activities or tasks the patient mightattempt outside of the treatment session (Q 38). Patients ap-peared to readily comprehend what therapists said to them (Q5, r), conveyed that they felt understood (Q 14, r), and had littled i f f i cu l ty beginning treatment hours (Q 25, r) . They were d e -scribed as ve r y accepting of therapists' comments and observa-tions (Q 42, r) , compliant and deferential (Q 20, r) , undemand-in g (Q 83 , r ) , and collaborative (Q 87, r) . This stance m ay havebeen in response to the active control (Q 17, 31) therapists as-sumed, although it may be explained in part by the relativelyhigh levels of depression in this sample. Therapists frequentlyrestated or rephrased the patient's statements to c la r i fy them (Q65 ) , and there were fewsilences during the hours (Q12 , r).Theywere described as responsive and affect ively involved (Q 9, r)and didactic (Q 37), and they frequently explained some aspectof the therapy or instructed the patient about certain therapytechniques (e.g., to imagine a conversation with someone duringthe hour; Q 57). These therapists were not neutral; that is, theyexpressed opinions or took positions (Q 93, r), and they weres t rongly supportive, encouraging, and approving (Q 45).

Among the 10 items identified as most characteristic andl e a s t characteristic fo r psychodynamic a n d cognitive-behav-

ioral therapies, respectively, there were 9 items in common (6uncharacteristic and 3 characteristic), suggesting that there areimportant commonalities across these treatment modalities.

Differences and similarities in the therapy process acrosstreatments. D if f e r e n c e s between the two treatment modali-ties emerged more sh a r p l y in direct comparisons of Q-sorts oftherapy sessions. The Q-item ratings for the sample of psychody-namic (T V = 90) and cognitive-behavioral (N = 96 ) therapy ses-sions were compared by submitting each of the 100 Q-items to at test (two-tailed). Process in the two treatment modalities wass t r ik in g l y d i f f e r en t , with 57 of 100 items s ign i f ican t ly d i f f e r e n -tiating the two treatments, 44 at the p < .001 level of s ign i f i -cance and 13 at p < .01 (p < .01 was selected to reduce experi-mentwise error; see Table 4). In the presentation of the resultsof this comparison, statements are made that a given Q-item ismore or less characteristic of a treatment, when sometimes theQ-item is rated as generally characteristic (or uncharacteristic)fo r both treatments in the Q-continuum, and hence such state-ments are relative in nature. The fo l lowing set of items aregrouped according to general conceptual similarity. Inspectionof Table 4 w i l l reveal additional items that supplement thissummary characterization.A s might be expected, there were many d i f f e r en c e s in thera-pist technique. It was more characteristic for psychodynamictherapists to encourage or fac i l i ta te patient speech (Q 3), iden-t i fy recurrent patterns in patients' experience or behavior (Q62), point out the use of defensive maneuvers used by the pa-tient to ward off threatening information or f e e l i n g s (Q 36 ) ,draw attention to thoughts or f e e l i n g s regarded by the patient asunacceptable (Q 50) or not clearly in awareness (Q 67), andg e n e r a l l y promote th e experienceo f affect (Q 81). I n contrast.


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C O M P A R I N G T H E R AP Y P R OC E SSE S 311Table 3Rank Ordering ofQ-Items for Patientsin Cognitive-Behavioral Therapy

PQS i tem and no. M10 Least characteristic i t e m s

Q 9. T is dis tant and aloof.Q 5. P has difficulty under s tand ing the T 's com m en ts .Q93. T is neut r a l .Q 42. P rejects T 's c o m m e n t s an d observations.Q 20. P is provocative, tests l im i t s of the r apy relat ionship.Q 14. P does no t feel understood by T.Q 25. P has difficulty beg inning th e hour .Q 83. P is dem and ing .Q 87. P is control l ing.Q 12. Silence occurs dur ing the ho ur .

1.542.422.562.632.813.882.973.013.023.08

10 Most characteristic i t e m sQ 17. T actively exerts control over th e in t e r ac t ion . 7.96Q 37. T be haves in a teacher- like (didact ic) m a n n e r . 7.82Q 30. Discussion centers on cognitive t h em es . 7.78Q 69. P ' s cur r en t or recent life si tuation is emphasized. 7.50Q 38. There is discuss ion of specific activities or tasks for the P to a ttem pt outs ide of session. 7.46Q 31 . T asks fo r m o r e i n fo rma t ion or elaboration. 7.43Q 35. Self-image is a focus of discussion. 6.95Q 57. T explains ra tionale behind his or her t echnique . 6.94Q 45. T adopts supportive stance. 6.91Q 65. T clarifies, restates, or rephrases P 's c o m m u n i c a t i o n . 6.80Note. Average i tem m ea n s (H o u rs 1 ,5 , and 14). T h e n u m b e r of t r e a t m en t hour s = 96 . PQS = Psychothe r -ap y Process Q-set; T = the rap is t ; P = p a t i en t .

cognitive-behavioral therapists more f requen t ly provided di-rect adviceand guidance (Q27), suggested spec i f i c activities(Q3 8 ) and, in an effor t to help patients with interpersonal diff i -culties, attempted to explain the meaning of the behavior ofother people in the patient's l i fe (Q 43) and encouraged new ord i f f e r e n t ways of behaving with them (Q 85). Therapy sessionstended to have a more specific focus (Q 23), and greater atten-tion was given to cognitive b e l i e f s (Q 30). Unlike psychody-namic therapists, cognitive-behavioral therapists more usuallyacted to avoid or suppress patients' disturbing f e e l i n g s andideas (Q89).

Therapist stance, and the ensuing quality of the dyadic inter-action, was also strikingly d i f f e r en t across treatment modali-ties. Psychodynamic therapists were more distant or f o r m a l (Q9; although therapists in both modalities were generally de-scribed as uncharacteristic in this regard) as well as more neu-tral (Q 93). They were judged to be more empathic (Q 6) andmore l ike ly to correctly perceive their patients' emotional stateand the nature of the interaction (Q 28). Cognitive therapistswere more act ively controlling (Q 17) and didactic (Q37); theywere also much more approving and encouraging (Q 45) andreassuring (Q 66). However, these therapists were also judgedby our raters to be more tactless (Q 77) and more condescend-in g or patronizing (Q 51) (again, these Q-item means were inthe uncharacteristic range for both treatments). In addition,their own emotional reactions more o f t e n intruded into thetreatment in an u n h e l p f u l way (Q24). However,w h e n disagree-ment or conf l ic t arose, cognitive-behavioral therapists weremore accommodating or appeasing (Q 47).

Psychodynamic therapies, relative to cognitive-behavioraltreatments, were clearly more evocative of patient emotional

experience. Patients in dynamic therapies more o f t e n ex-pressed angry or aggressive f e e l i n g s (Q 84) or struggled to con-trol strong emotions (Q 70); they also tended to be less compli-ant and more demanding (Q 83) and controlling (Q 87), andthey experienced more ambivalent(Q49), critical, or antagonis-tic (Q 1) feelings toward their therapists. In this context ofheightened patient emotional states and patients' affective reac-tions to the therapist, the therapy relationship was a more im-portant focus of discussion (Q98). Therapists more frequentlyinterpreted the transference (Q100) and reformulated patients'in-therapy behavior in sucha way as to give it a new or d i f f e r en tmeaning (Q82). Patients in dynamic treatments were judged asa c h i e v i n g more self-understanding or insight than those in cog-nitive-behavioral therapies (Q32).

Thirty-eight Q-items did not s ign if ican t ly distinguish psycho-dynamic and cognitive-behavioral therapy processes, and ofthese, 26 were descriptors of patient attitudes or emotionalstates. In other words, what was not d i f f e r en t concerned pri-marily the patients, not the treatments. There were no differ-ences, for example, in patient levelsof anxiety or guilt, f e e l i n g sof inadequacy or in f er io r i ty , and depression or sadness (whichwas verycharacteristic of both patient samples). Patients' senseof trust, abi l i ty to understand their therapists, and sense off e e l i n g understood was comparable in both treatments. Theywere rated as equivalent in their concerns about becoming de-pendent and their wish to re ly on therapists to solve their prob-lems. In both treatments, patients were equally committed tothe workof therapy and similar in their levelsof positive expec-tations about the treatment and the sense of fe e l ing helped. It isl ike ly that these kinds of patient attitudes and concerns arecommon in all modes of treatment.


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312 EN R I C O E . JO N ES A N D ST EV EN M . P U LO STable 4Differences Between Q- It em M eans fo r P sychod ynamic and Cognitive-Behavioral Therapies

P s y c h o d y n a m i c Cogni t ive-behaviora lPQS it em and no . t r e a tm e n t t re a tm e n tMore character is t ic of p s y ch o dy n a m i c t r e a tm e n t

3. T's r emarks ar e a imed a t facili tating P's speech.6 . T is sens i t ive to P's feelings, a t tuned to P;e m p a t h i c .9. T is dis tant , aloof (vs . responsive andaffec t ionately involved) .22. T focuses on P's feel ings of guil t .28 . T accurately perceives the therapeut ic process .29 . P talks of wanting to be separate or dis tant .32 . P achieves a new understanding or insight.36 . T points out P 's use of defensive m aneuve r s ( e .g . ,undoing , den ia l ) .40. T makes in te rpr e ta t ions referring to actual peoplein P' s l i f e (vs . makes general or imper sonali n t e rpre t a t i ons) .50. T draws at tent ion to feelings regarded by P asunaccep tab le ( e .g . , anger , envy , or exc i t em ent ) .6 2. T identif ies a r ecur r en t theme in P ' s exper ience orconduct .67 . T interprets warded-of fo r unconscious wishes ,feelings, or ideas .72 . P under s tands th e n a t u r e of the r apy an d what isexpected.81. T emphasizes P 's fee l ings t o h e l p h i m / h e rexper i ence them more deep ly .82. P's behavior during th e hour is r e formula t ed by Tin a way not expl ic i t ly recognized previou sly.83. P is d e m a n d i n g .84. P expresses angry or aggressive feelings.9 1 . Memories or reconstruct ions of infancy an dchildhood are topics of discussion.92. P's feel ings or percept ions are l inked to s i tuat ionsor behavior of the past.93. T i s neu t r a l .100. T draws connec t ions be tween the the r apeu t i cre lationship and othe r rela t ionships.1 1 . Sexual feel ings an d exper iences are discussed.86 . T is conf ide nt or self-assured (vs . unce r tain ordefensive) .87. P is control l ing.98. The therapy relat ionship is a focus of discuss ion.41 . P 's aspirations or a m b i t i o n s ar e topics ofdiscuss ion.46 . T c o m m u n i c a t e s with P in a clear , coherent s tyle .49. P exper iences ambivalent or conf l icted feelingsabout T.70 . P struggles to cont ro l feelings or impul s es .88. P br ings up significant issues and mater ial .1. P verbalizes negative feelings (e.g., criticism,host i l i ty) toward T (vs . making approving ora d m i r i n g remarks).

6.2**6.8**2.4**5.4**6.6**5.9**5.6**5.4**6.3**6.2**7.0**6.3**5.6**6.6**5.3**4.1**6.1**6.3**6.8**5.8**5.1**5.3**6.4**4.1**5.3*5.9*5.9*4.8*4.5*6.9*4.2*

4. 85.91.54. 45.64.94.73. 65.04. 45.74. 24.63. 24. 53.04. 84. 54. 92.64.04. 55.83.04. 65.25.54. 34.06 .33. 7

More charac t e ri s t ic of cogni t ive-behaviora l t r ea tm ent15. P does no t ini t iate topics ; is passive.1 7. T actively exerts control over th e interaction (e.g.,s t ructur ing, introducing new topics).21 . T self-discloses.24. T's own em ot ional conflicts intrude into th erelat ionship.25. P has difficulty beg inning the hour .27. T gives expl ici t advice and guidance (vs . deferseven w h e n pressed to do so).30. Discuss ion centers on cognit ive t h e m e s (i.e. ,about ideas or bel ief sys tems).37 . T behaves in a teacher-like (didactic) m a n n e r .

1.94.93.53.02. 13.95.03.9

3.4**8.0**5.4**4.1**3.0**6.3**7.8**7.8**


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C O M P A R I N G TH E R A P Y P R O C E S S E S 313Table 4 (continued)

PQS i t em and no . P s y ch o d y n a m i ct r e a t m en t Cognit ive-behavioralt r e a t m e n tMore character is t ic of cognit ive-behavioral treatm en t (continued)

38 . There is discussion of specific activit ies or tasksfor P to a t t empt ou ts ide of session.45. T adopts supportive s tance.5 1 . T condescends to , or patronizes P.57. T expla ins ra t ional e beh ind h is /her t echn ique o rapproach to t r ea tmen t .66 . T is directly reassuring.6 8. Rea l vs . fan ta s ized m ean ings of experiences ar eact ively different iated.74 . H u m o r is used.76 . T suggests that P accept responsibil i ty for h is /herprobl ems .77. T is tactless.79. T c o m m e n t s on changes in P 's mood or affect.80. T presents an experience or event in a dif ferentperspective.85. T encourages P to try new ways of behav ing withothers .

89. T acts to s trengthen defenses.2. T draws attention to P's nonverbal behavior (e.g.,posture, gestures) .23 . Dialogue has a specific focus.43 . T sugges ts th e m ean ing o f others ' behavior .47 . W h e n th e in teraction with P is d i f f i c u l t , Taccommoda tes in an effort to improve rela t ions.6 1 P feels shy and embarrassed (vs. un-self-consciousand assured).

4. 34.62.74.03.54.94.84. 42.74 .45.84. 82.64. 35.24.74.03. 9

7.5**6.9**4.1**6.9**5.4**6.3**5.7**5.2**3.7**5.1**6.6**5.8**5.9**4.6*5.9*5.3*4.6*4.6*

Note. Endpoin t s ar e extremely characteristic (9) and extremely uncharacteristic (1). Signif icant dif ferenc esbe tween Q -i t em m ea n s w e r e o b t a in ed by two-tailed t tes ts ; d fs = 1 , 60. PQS = Psycho therapy P rocessQ-se t ; T = th e rap is t ; P = pa t i en t .* p < . 0 1 . * * p < . 0 0 1 .

Process Factors: The i r Correlation to Therapy OutcomesT he compar ison of Q-i tems across th e t r eatment modali t i esdem onst rates large and im por tan t dif fe rences . The quest iontha t t h en arose w as whether there were underlying factors tha tt he two t r e a tmen t s shar ed i n common and , fu r the rmore ,whet he r any such d im ensions m ight be associated wi th t reat-m e n t effectiveness. The Q-ratings for all subjects at all threet ime po in ts (N = 186 t r eatment hours) were subjected to a factoranalysis (pr incipal-com ponents m ethod) . The factor analysisyielded four conceptually in te rpre table factors af ter v a r i m a xrotation, which together accounted for 42% of the var iance inQ-sort d escriptions. T he i tem s t ha t bes t def ine th e factors arelisted in Table 5.Factor 1, Psychodynam ic Techn ique , reflects therapists ' ac -t ions and techniques usua lly associated wi th psyc hodynam icapproaches . Factor 2, Cognitive-Behavioral Technique, cap-tu res therapists' activity from this theoretical perspective. Fac-tor 3, Patient Resistance, reflects the extent to which a patientwas or was not able to create a collaborative, working alliancewith th e therapis t ; felt c o m m i t t e d to the t r e a tmen t ; and feltt rus t ing, hop efu l , unders tood , and he lped . Factor 4 , Neg at ivePatient Affec t , reflects th e extent to which pat ien ts felt de -pressed and anxious or exper ienced o ther t roublesome affectdur i ng therap y sessions. Factor scales were constructed by aver-aging th e re levant PQS i t e m s fo r each of the four factors after

reversing th e coding of i t ems that were negative indicators offactors. The alpha re l iabi l i t i es were .89, .93 , .91, and .77 forPsychodynami c Technique , C ogni t ive-Behavioral Technique ,Pat ien t Resis tance , an d Negative Patient Affec t , respectively.It s e em ed impor tan t to establish th e validity of the labelsselected to designate especially Factors 1 and 2. In Table 5, the10 i t ems t ha t compose th e factor Psychodynamic Techn ique ar eam ong the Q i tem s that are rated as significantly m ore de sc r ip -tive of the p sychodynam ic the r apy sam p le (a ll ps < .001); sim i-larly, th e 10 i t em s that compose th e factor Cognitive-BehavioralT echn i que are am ong those that are m ore descr ip tive of thecogni t ive-behavioral therapy sample (al l ps < .001). The factthat the factor ial ly def ined i t ems are uniqu e to , and to tally en-capsulated wi thin , the i t ems tha t dis t inguish the two therapysample s a ff i rms the use of the psychodynamic t e chn ique andcogni t ive-behavioral t ech nique des ignat ions and const itu tes ev-idence tha t these factors are speci f ic to the respect ive t reat-ments .To d e t e r m i n e w h e t h e r th e four process factors were asso-ciated wi th t reatment outcomes , we calculated partial correla-tions (controlling for pretreatment) of outcome scores and pa-t i en t scores on the factors. I t was anticipated that hig h scores onPsychodynami c Technique would be associated with posit iveou t com e in p sychodynam ic t he r ap i e s and tha t h igh sco re s onCogni t ive-Behavioral Technique would show a s im i lar associa-t ion wi th effectiveness in cogni t ive therapies . Surpr is ingly, his


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31 4 E N R I C O E . J O N E S A N D S T E V E N M . P U L O STable 5Process Factor Items and Loadings

PQS i t em and no . Load i ngFactor 1: P s y c h o d y n a m i c T e c h n i q ue

8 1 .93.6 7.36 .

T e m p h a s i z e s P ' s fee l ings t o h e l p h i m / h e r e xp e r ie n c e t h e m m o r e d e e p l y .T is neut ra l .T i n t e rp r e t s warded-off o r u n c o n s c i o u s w is h e s , feel ings , or ideas .T poi n t s out P ' s use of d e fe n s iv e m a n e u v e r s ( e .g ., u n d o i n g , d e n i a l) .92. P's fee l ings o r perc ep t i ons ar e l i nk ed to si tua t ions or b e h a v i o r of the past .50 . T d raws a t t en t i o n t o feel ings r ega rd ed by P a s unaccep t ab l e ( e . g . , anger , e n v y , ore x c i t e m e n t ) .Memor i es or r econs t ruc t i ons of i n fa nc y and ch i ld hoo d a r e t op i c s of d is cus s ion .100. T d raws conne c t i on be t ween t he t he rap eu t i c r e l a t i onsh i p and o t her re l a t i onsh i ps .82 . P ' s behav i or d ur i ng the hou r i s r e form ula t ed by T i n a way not expl ic i t lyr ecogni zed p r ev i ous ly .6 2. T i d en t i f i e s a r ecur r en t t hem e i n P ' s ex pe r i ence or cond uc t .

9 1 .

.8 1

.80.7 0.6 2.6 1

.58.57.5 0.50.50

Fac tor 2 : C o gni t i v e- Be hav i ora l Te chni q ue3738

30

T b ehav e s in a t ea cher -l i ke ( d i d ac t i c ) m ann er .Ther e is d i scuss i on of spec i f ic act iv i t ie s or tasks for P to a t t e m p t o u t s i de ofsess ion.T acts to s t r e n g t h e n d e f e n s e s .Di scuss i on c en t e r s on cogni t i v e them es ( i . e ., about i d ea s or be l i e f sys t ems) .57 . T expla ins rationale beh i nd his/her t echni q ue or approach to t r ea t men t .27 . T g i v es ex p l i c it ad vi c e and gu i d ance ( v s . d e f e r s ev en wh en p r es sed t o d o so).17 . T act ive ly ex er t s cont ro l ov er t he i n t e ra c t i on ( e .g . , s t ruc t ur i ng , and /ori n t r o d u c i n g new topics) .51 . T cond escend s t o , o r p a t r o n i z e s P .21 . T self-discloses.66 . T i s d i r ec t ly r ea s sur i ng .

.7 6.7 6.74.7 3

.7 3.7 2.6 7

.60Factor 3: Pa t ien t Res i s t ance

42 . P rejects (vs. accepts) T's comments and observations. .7914 . P does not feel und er s t ood by T. .734 9 . P ex per i ences amb i v a l e n t or conf l i c ted fee l ings a b o u t T . .7 144. P feels wary or susp i c i ous ( v s . t rus t i ng an d s ecure) . .7 058 . P r es is t s ex a m i n i ng t hough t s , r ea c t ions or m ot i v a t i ons r e l a ted t o p rob l em s . . 691 . P verbal izes negat ive fee l ings (e.g., c r i t i c i sm, ho st i l i ty) toward T ( v s . m ak esa p p r o v i n g or ad m i r i ng r em a rk s ) . . 6 620. P is prov oca t i v e , t e s ts l i m i t s of the t h e r a p y r e l a t i o n s h i p ( vs . b e h a v i n g in ac o m p l i a n t m a n n e r ). .6 13 9 . There i s a com pe t i t iv e q ua l i t y t o t he r e l a t i onsh i p . . 577 3 . P i s com m i t t ed t o t he work of t he rapy . - .7 295. P fee ls h e l p e d . -.749 7. P i s i n t rospec t i v e , r e ad i l y ex p lor es i nner t hought s , and fee l ings. -.6255. P conv e ys pos i t i ve ex pec t a t i ons about t he rap y . -.61

Factor 4: Pa t i en t Nega t i v e Af f e c t94. P feels sad or depressed (vs . joyo us or che e r fu l ) . .7 059. P feels i nad eq ua t e an d i n fe r io r (vs. effec t ive and super i or ) . .6 726. P experiences discomfort ing or painful affec t . .6 07 1 . P i s self-accusa tory; expresses sham e or gu i l t . .597. P i s anxio us or t ense (vs . ca lm and relaxed) . .56

Note. PQS = Psychot herapy Proces s Q- se t ; T = t h e r a p i s t ; P = p a t i e n t .

was not the case . P sychodyn am i c T echn i que w as significantlycor re l a ted wi t h p a t ien t i m p rovem en t on four of f ive outcom escales for the cogni t ive-behavioral t rea tment sample , and Cog-ni t ive-Behavioral Te chniqu e showed l i t tle or no associa tionwith outcom e (see Table 6 ) . The correla tion for Psychodynam icTec h n iqu e t o ou tcom e i n p sychodynam i c t he rap i e s showed anear-significant t ren d, where as Cog nit ive-Behavioral Tech-nique showed a s ignif icant negative associat ion on one of fouro u t c o m e scales in t h i s t r ea t m en t s am p le . F act o r 3 , Pat i ent Res i s-

tance , was signif icantly negat ively correla ted wi th outcome inb o t h t r ea t men t s amp les (five of f ive outcom e scales in cogni-tive-behavioral treatments and two of fourscales in psychody-nam ic therapies). Factor 4, Pat ient N egative Affec t , was nega-tively correla ted wi th outcom e in cogni t ive-behavioral the ra-p ies on the MMPI-.D, conversely, i t was posi t ively associatedwi th outcome on one o f four scales (therapist-rated BPRS) inp sychodynami c t r ea t men t s . T h i s d i s c rep ancy may reflect th et e nde ncy , a l ready cap t u red in the analys i s of i nd iv idua l Q-


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C O M P A R I N G T H E R A P Y P R O C E S S E S 3 1 5Table 6Process Correlates of Outcome

Cognitive-behavioral the rapy Psychodynamic the r apyProcess factor BD I A TQ HRSD-17 MMP l- D R D S O C R BPRS BPRS(therapis t) (evaluator) SCL-90-R

1.2.3.4.Psychodynamic techniqueCognitive-behavioral t e ch n i q u ePat i en t re s is tancePatient negat ive affect

-.18-.06.35**-.01-.31**.01.30**.18

-.33**-.02.39***-.09-.47***.09.29*.38**

-.39***.08.33**.1 9-.30*.07.34*-.05

-.19.04.65****-.44**-.20.35**.1 7-.08

-.04.04.07.04Note. A nega t ive correlat ion reflects a positive association with o u t c o m e . A ll correlat ions ar e p a r t i a l correla tions control l ing fo r pat ien t p re t rea t-m e n t scores, excep t fo r overal l c h a n g e r a t i n g ( OC R ), which is a Pearson cor re la t ion .BDI = Beck Depress ion I nven to ry ; A T Q = A u t o m a t i c T h o u g h t sQues t ionnai r e ; H R SD - 1 7 = H a m i l t o n Rat ing Scale fo r Depress ion; MMPI-.D = M in n e so ta Mult i phas i c Personal i ty I nven to ry Depress ion sca le ;RDS = Raskin Depress ion Scale ; BPRS = Brief Psych iatr ic Rating Scale; SCL-90-R = Sy m p t o m Distre ss Check l i s tRevised .*p


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316 E N R I C O E . J O N E S A N D S T E V E N M . P U L O Srience is encouraged, and insight is viewed as a higher orderlevel of knowing that is metacognitive in nature.

Many elements of a developmental approach to cognitive-behavioral therapy are contained in the process factor which ishere designated as Psychodynamic Technique. The extent towhich these cognitive-behavioral therapies contained ingre-dients of psychodynamic technique was associated with posi-t ive outcome. In f ac t , this factor was most consistently asso-ciated w i t h favorable treatment outcome in both psychody-namic and cognitive-behavioral therapies. The common coreof therapeutic process across d i f f e r e n t approaches may well belocated in this domain.

Process research, more than comparative outcome studies oreven experimental (extraclinical) tests, is likely to be useful inproviding evidence for or against the theoretical propositionsthat guide psychologically mediated interventions. A f t e r a l l ,theories of psychotherapy ultimately derive from observationsabout clinical phenomena and change processes.The challengelies in developing methodologies that begin to capture e f f ec-t ively the complexities of the therapy process, particularlythose that are applicable across theoretical schools with theird i f f e r e n t clinical constructs and diverse descriptive language.This comparative study of the therapy process represents a stepin that direction.

Refe r encesB e c k , A . T ., R u s h , A . J., Shaw, B. F, & E m e r y , G. (1979) . Cogni t ive theory

of depression. New York: Gui l ford Press.Be ck , A . T., War d , C . H . , M ende l s on , M . , M ock , J . E. , & Er b augh , J . K .(196 1) . A n i n v e n t o r y fo r m e a s u r i n g d e p r e s s io n . Archives of GeneralPsychiatry, 4, 561-571.Block , J. (1978) . The Q-sort method in personal i ty assessment and psy-chiatric research. Sp r ing f i e ld , IL : Char l e s C Thomas. (Or ig ina l w or kp u b l i s h e d 1 9 6 1 ) .Der oga t i s , L. R. , L i p m a n , R. S., R ick e t s , K.., U h l e n h u t h , E. H ., & C o v i ,L. (1974). T he Hopkins Symptom Checklist (HSCL): A sel f-repor ts y m p t o m i n v e n t o r y . Behavioral Science, 19,1-15.DeRub e i s , R . , H o l lon , S. D., Evans , M . D . , & Bem is , K . M . (1982). C anp s y c h o t h e r a p i e s fo r dep r e s s ion b e d i s c r i m i n a t e d ? A s y s t e m a t i c in -

vestigation of cognitive therapy and interpersonal therapy. Journalof Consulting and Clinical Psychology, 50, 744-756.E l k i n , L, Shea , T ., Wa tk ins , J., I m b e r , S., Sotsky, S., Collin s, J., Glass , D.,P i l k o n i s , P . , Leb e r , W, D oche r ty , J., Fiester, S., & Parloff , M. (1989).National Institute of Mental Health treatment of depression. Collab-or a t ive r e s ea r ch p r og r am: Gene r a l e f f ec t ivenes s o f t r e a t m e n t s . A r-chives of Genera l Psychiatry , 46 , 971-982.Fr ie s w yck , S. H .. A l l e n , J. G., Col s on , D . B., Coyne, L. , Gabbard, G. Q,Horwitz , L., &N e w s o m , G. (1986). Therapeutic a l l i ance : Its place asa p r oce s s and ou tcom e var iab l e in dynam ic p s ycho the r ap y r e s ea r ch .Journal of Consulting and Clinical Psychology, 54 , 32-38.Gr eens on , R . R . (1 9 6 7) . The technique and pract ice of psychoanalysts.New York : In t e r na t iona l Un ive r s i ty P r e s s .G u i d a n o , V F. (1987) . Complexity of the self N e w York: Gui l fo r d Press.H a m i lt o n , M . (1967) . Deve lop m en t o f a r a ting s ca l e f o r p r im ar y de -p r e s s ive i l l n e s s . British Journal of Social an d Clinical Psychology, 6,278-296.Hathaway , S. R., & M c K i n l e y , J. C. (1983) . Minnesota Mul t iphasic Per-sonality Inventory: Ma nual for administrat ion an d scoring. M i n n e a p -o l i s : U n ive r s i ty o f M inn es o ta Press.

H ol lon , S . D , D eRub e i s , R . J., & Evans , M. D. (1987) . C a u s a l m e d i a t i o no f c h a n g e i n t r e a t m e n t f o r d e p r e s s io n : D i s c r i m i n a t i n g b e t w e e n n o n -specif ici ty an d noncausal i ty . Psychological Bulletin, 102, 139-149.H o l l o n , S. D, D e R u b e i s , R. }.. Evans , M. D, W i e m e r , M. I, Gar vey ,M . I , Grove, W M., & T u a s o n , V B . (1989). Cognitive-therapy, phar-macotherapy and combined cogni t ive-pharmacotherapy in the t reat-men t of depression. Manuscript submitted fo r publication.

H ol lon , S. D, & K e n d a l l , P. G. (1 9 80) . Cog n i t ive s e l f - s ta t em en t s ind e p r e s s i o n : D e v e l o p m e n t o f a n A u t o m a t i c T h o u g h t s Q u e s t i o n n a i r e .Cogni t ive Th erapy and Research, 4, 383-395.

Jacobson, N . S., & Truax, P. (1991). Cl inical s ignif icance: A statisticala p p r o a c h t o d e f i n i n g m e a n i n g f u l change in p s ycho the r ap y r e s ea r ch .Journal of Consulting and Clinical P sychology, 59 , 1 2-1 9 .J o n e s , E. E . (1 9 85 ) . M a n u a l for the psychotherapy process Q-set . U n-published manuscript, Univers i ty of Cal ifornia , Berkeley.Jones , E. E., C u m m i n g , J . D , & H o r o w i t z, M . J. (1988) . A n o t h e r lo o k a tth e n o n s p e c i f i c h y p o t h e s i s o f t h e r a p e u t i c e f f ec t i venes s . Journal o fConsulting and Clinical Psychology, 56 , 48-55.

Jones, E. E., Hal l , S., & Parke, L. A. ( 1991) . The process of change : TheBe rk e l e y P s ycho the r ap y Res ea r ch Gr oup . In L . Beu t l e r & M . Cr ago(Eds.) , Psychotherapy research: An in ternat ional review of program-mat ic s tudies (pp. 98-107). W a s h i n g t o n , D C : A m e r i c a n P s y ch o lo g i -cal Association.Jones , E. E., K r u p n i c k , J. H ., & K e r i g , P. K. (1987) . S o m e g e n d e r ef fect sin a b r i e f p s ycho the r ap y . Psychotherapy, 24, 336-352.Jones , E. E., P ar ke , L . A ., & P ulos , S. (1992). H o w t h e r a p y i s c o n d u c t e din th e private consul t ing room: A m ul t ivaria t e description o f b r i e fp s y c h o d y n a m i c t r e a t m e n t s . Psychotherapy Research. 2, 16-30.Lu bo rsk y , L., & DeRub e i s , R . J . (1984) . The us e o f p s ych o the r ap y t r ea t -m e n t m a n u a l s : A s m a l l r e v o lu t i o n in p s y c h o t h e r a p y r e s e a r ch s t y l e .Clinical Psychology Review, 4 , 5-14.M a h o n e y , M . J . (1988) . The cogn i t ive s c i ence s and p s yc ho the r ap y : P a t -t e r n s in a d e v e l o p i n g r e l a t io n s h i p . I n R . Dob s in (Ed.) , Handbook o fcogni t i ve behavioral therapies ( p p . 357-386). N e w York : Gu i l fo rdPress .M a r z i l l e r , J. S. ( 1 9 8 6 ) . C h a n g e s in dep r e s s ive b e l i e f s : A n a n a l y s i s o fBeck 's cogn i t ive th e r a p y fo r dep r e s s ion . In Advances in cogni t ive-be-havioral research and therapy (V o l . 5 , p p . 89-114). San D iego , CA :A c a d e m i c P r e s s .M i l l e r , R . C , & B e r m a n , J . S . (1983) . The eff icacy o f c o g n i t i v e b e h a v i o rthe r ap ie s : A qua n t i t a t ive r ev iew o f th e r e s ea r ch ev idence . Psychologi-ca l Bulletin, 94, 39-53.Ove r a l l , J. , & Gor ham , D . (1 9 6 2) . The Br ie f P s ych ia t r i c R a t ing Sca l e .Psychological Reports, 10 , 799-812.Persons , J . B. (1991) . P s y c h o t h e r a p y o u t c o m e s t u d i e s d o n o t a c c u r a t e l yr e p r e s e n t c u r r e n t m o d e l s o f p s y c h o t h e r a p y : A p r o p o s e d r e m e d y .American Psychologist . 46 , 99-106.R a s k i n , A ., S c h u l t e r b r a n d t , J. G., Reatig , N ., & M c K e o n , J. J. (1970).D i f f e r e n t i a l r e s p o n s e t o c h l o ro p r o m a z i n e , i m i p r a m i n e , a n d p l a-cebo. Archives of Genera l Psychology, 23 , 164-173.S m i t h , M. S., Glas s, G . V , & M i l l e r , T. I. (1980). The benefits of psycho-therapy. Bal t imo r e : Johns H op k ins U n ive r s i ty Press.Spitzer , R . L . , End ico t t , J., & R o b i n s , E. (1979). Research Diagnost icCriteria (RDC) for a selected group of funct ional d isorders (3rd ed.).N e w York: B i o m e t r i c R e s e a rc h , N e w York Sta t e P s ych ia t r i c In s t i -tu t e .Stiles, W B., Shap i r o , D . A ., & El l io t t , R . (19 86 ) . A r e a ll p s ycho the r a-p i e s equ iva l en t? American Psychologist , 41 , 165-180.

Received February 11,1992Revision received May 4,1992

Accepted May 4,1992

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Comparing the Process in Psychodynamic and Cb Therapies

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