Copyright 1990 by the American Psychological Association, Inc. 0022-006X/90/$00.75

Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 3,265-272

Psychotherapy Process Research: Progress, Dilemmas, and Future Directions Charles R. Marmar

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Department of Psychiatry University of California, San Francisco and Department of Veterans Affairs Medical Center, San Francisco The first several decades of psychotherapy process research have produced advances in measure development and substantive findings of process-outcome relations. A recent paradigm shift toward sequentially patterned, significant change episodes is described, emphasizing segmentation of process by meaningful patterns wherever they occur. Theoretical, psychometric, and data analytic dilemma are reviewed. Strategies are offered that may enhance future research efforts. These include greater attention to construct validity of measures, the relation of process to phase-specific outcome criteria, and the continuing development of multivariate data analytic strategies that take into account Patient X Treatment interactions as well as the sequential dependency of process data. The development of a national archive of significant change events is recommended to advance modeling of the change process, segmentation, construct validation of measures, integration of qualitative and quantitative approaches, and development of a cross-theoretical language for therapy process.

The empirical study of the psychotherapeutic process is a young discipline, primarily spanning the last 30 years. Major milestones in the evolution of this area of inquiry as a coherent field attest to the recency of the history. The Society for Psychotherapy Research was founded in 1968 and in a short time has catalyzed an international effort in this area. Kiesler's (1973) landmark book was the first devoted exclusively to process research; it emphasized the first 20 years of progress in measures and methods development. In their comprehensive presentation of developments in the field since the publication of Kiesler's work, Greenberg and Pinsof (1986) provided a coherent organization for the understanding of the second developmental phase, which they labeled "the new process perspective in psychotherapy research" (p. 3). These second generation studies signal a paradigm shift toward multidimensional, episode anchored, sequentially patterned approaches to the investigation of change processes (Greenberg & Pinsof, 1986; Rice & Greenberg, 1984). Orlinsky and Howard's (1978; 1986b) encyclopedic reviews of the conceptual, methodological, and substantive findings in process outcome research have served to catalyze a growing international effort in identifying change processes that impact on outcome. Their reviews underscore the importance of the therapist/patient relationship, patient experiencing, and related variables in predicting the course of psychotherapeutic outcome.

Fundamental Methodological Issues in Process Research Formulation and Interrelation of Variables The psychotherapy research enterprise begins with the articulation of a theoretical model of the change process and the generation of variables that arise out of that theoretical system. In his review, Kiesler (1973) asserts that the selection of a theoretical variable for study is the essential first step in psychotherapy process study. This selection is intimately related to the resolution of other methodological problems. Much methodological confusion has resulted from not giving priority to theoretical considerations, (p. 31)

Having articulated a theoretical process of change, the investigator is faced with multiple challenges in creating an optimal set of variables to capture the process. The field has been characterized by a split: On one hand are discrete approaches that yield easier to quantify, more reliable, but less sophisticated variables, and on the other hand are more abstract, complex variables. The latter are often difficult to operationalize, yield lower interrater reliabilities, and are more difficult for clinical judges of different theoretical backgrounds and levels of experience to rate. A recommended solution has been to study variables at the middle level of abstraction, but this level is without generally agreed upon criteria. When one attempts to designate the necessary and sufficient set of variables to capture the relevant dimensions of c mplex change processes, a question arises as to the interrelation that exists among the various levels of abstraction that characterize the variables. An ad hoc approach that simply measures multiple dimensions and attempts to reconstruct the gestalt of processes on a purely empirical basis is likely to meet with difficulty. Greenberg and Pinsof (1986) have argued for the organization of variables in a hierarchical progression from small observable units of clearly defined behaviors to longer patterns

A preliminary version of this article was presented as the presidential address to the 20th Annual Meeting of the Society for Psychotherapy Research, June 21-24,1989, Toronto, Ontario, Canada. Correspondence concerning this article should be addressed to Charles R. Marmar, Department of Veterans Affairs Medical Center, San Francisco; Box 116P, 4150 Clement Street, San Francisco, California 94121.

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that provide broader contexts and color the meaning of individual units of patient and therapist activity. They describe four levels organized hierarchically from small, discrete units to long-term patterns: (a) content, the manifest or literal meaning of discrete communicative acts; (b) speech act, the intended impact of the communication on the listener; (c) episode, a complete, communicative routine with an identifiable opening and closing sequence, such as discussion of the patient's conflicts with an important figure focused on a recent relationship episode; and (d) relationship, a longer pattern of the ongoing relationship of patient and therapist, for example, characteristics of the therapeutic alliance across several sessions. In an approach called Configurational Analysis (Horowitz, 1987; Horowitz et al, 1984), three levels of phenomena are specified. The first level, states, is defined as observable, recurrent patterns of patient behavior organized around a dominant affect. The second level, role relationship models, includes the following: (a) the social alliance or real relationship that is based on each party's reactions to the other's social background, physical characteristics, intellect, style and taste, warmth, and other real attributes; (b) the therapeutic or working alliance, involving the commitment and capacity of both parties to engage in the working strategies of the treatment; and (c) transference and countertransference relationship models, both positive and negative reactions of each partner to the other that are based on situationally inappropriate relationship models that emphasize unresolved conflicts. The third level, information processing, traces the processing of salient events; examines the matching of the events against enduring attitudes, such as self-images and models of the world; characterizes the emotions generated when incoming information is incongruent with existing models; and specifies the controls (coping and defensive mechanisms) directed at regulation of emotions and access to conscious experience of ideas. Integration across levels occurs as central role relationship models are specified for each state and as shifts in information processing underlying state transition are described. This framework permits a segmentation of process data. Established process variables can be related to the model: For example, ratings of the therapeutic alliance are linked to role relationship models; and ratings of voice quality (Rice & Kerr, 1986) and depth of experiencing (Klein, Mathiew-Coughlin, & Kiesler, 1986) can be related to state episodes. Other systems for relating shorter to longer patterns have also been proposed (Cashdan, 1973;Goldfreid&Safran, 1986; Hill, Carter, & O'Farrell, 1983). The following questions remain: How comprehensive are these systems, how broad is the coverage of the relevant phenomena, how idiosyncratic to a particular school of treatment are these models, and how readily can validated process variables be integrated into these models?

The Development of Measurement Systems The past decade has seen a consensus emerge on the value of representing the patient's, therapist's, and independent clinical judge's viewpoints on the therapeutic process. Kiesler (in Greenberg & Pinsof, 1986) recently concluded, "It is quite gratifying to discover both process and outcome re-

searchers now routinely incorporating measures from multiple measurement perspectives including both therapy participants, observer judges, and significant others in the patient's environment" (pp. viii-ix). Recent work on the therapeutic alliance (e.g., Marmar, Gaston, Gallagher, & Thompson, 1989; Marziali, 1984b) and findings with the Therapy Session Reports (Orlinsky & Howard, 1986a) support this multiperspective approach in process research. The development of a mature measure of the psychotherapeutic process is a complex, multistep procedure encompassing generation of an initial item pool, choice of scoring formats, determination of dimensional structure, assessment of interrater reliability, and assessment of convergent, discriminant, and predictive validity. In measure development over the past three decades, there has been a greater emphasis on interrater reliability and predictive validity and less emphasis on issues of dimensionality and convergent and discriminate validity. For example, despite the growing body of evidence to support the importance of the therapeutic alliance as a predictor of outcome, there has been little emphasis on identifying and validating the specific components of this complex construct. The finding that alliance variables have robust correlations with outcome still leaves considerable uncertainty as to precisely what it is that various alliance systems measure (Marmar, Weiss, & Gaston, 1989; Gaston, Marmar, Gallagher, & Thompson, 1989; Horvath & Greenberg, 1990). In future psychometric studies, greater attention to issues of construct validity will help resolve the problems created by the proliferation of multiple and potentially redundant measures.

Problems in Segmentation Research on the psychotherapeutic process requires a strategy for segmenting the complex ongoing flow of the communication. Previous studies of word counts, phrases, thought units, turns of speech, or predetermined time periods have yielded less clinically useful results than hoped for, in part because such procedures mechanically group content without regard for the context-specific nuances in the therapeutic interaction (Kiesler, 1973). Knapp (1974), in a critical review of segmentation dilemmas, suggests a strategy of demarcation according to changes in overall patterning, marked wherever they occur. In a related critique, Orlinsky and Howard (1978), recognizing the progress in prediction of outcome by pretherapy or early treatment patient process variables, expressed concern that such univariate prediction "is certainly useful knowledge but it falls far short of the desired conclusion that certain features of process are productive of good or poor outcome" (p. 320). The last decade has seen a direct response to this fundamental critique, leading to the emergence of a new psychotherapy process research paradigm (Rice & Greenberg, 1984; Greenberg & Pinsof, 1986). This new research paradigm aims to isolate meaningful patterns relying initially on the human integrator as the best screening instrument for pattern identification. Within this new paradigm, the segments of interest are not random samples that often fail to capture the salient phenomena in the change process and are not frequency counts, but rather they are change episodes or change events studied in context. Events or episodes are defined as important markers of patient

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behavior during psychotherapy, and they particularly include transitions in levels of patient experiencing, insight, or mastery of problems. Ideally, events would be recognizable by external observers reviewing tape recordings or transcripts and would also be reported by patients or therapists as important change points in the treatment. Such events would not be restricted to facilitatory episodes but would include markers of treatment deterioration or dropout. Such events or episodes become particularly powerful organizers of the change process because they permit systematic study of therapist techniques leading to such transitions. Ratings of each episode are made along multiple dimensions in an effort to isolate the pattern of covariation of variables within and across episodes. The impetus for this paradigm shift includes both the recognition that aggregating process ratings without regard to context reflects a uniformity myth about psychotherapy processes (Kiesler, 1973) and the acknowledgment that patterns, rather than rates, should be the target of study (Gottman & Markman, 1978). The view that greater frequencies of occurrence of a process element uniformly represent better process without regard to individual patient differences, phase of therapy, patient state, patient capacity for absorption of process, or related contextual problems has led to confusing findings. As an illustration, there has been a strong hypothesis in brief dynamic psychotherapy research that greater frequency of parent-transference linking interpretations is associated with better outcome (Malan, 1976; Marziali, 1984a). Zero-order correlations of single process variables with outcome may hold true across highly selected populations, such as better functioning patients carefully selected for brief dynamic therapy. However, with less motivated and more disturbed patients in whom patient resistance is a problem, emphasis on parent-transference linking interpretations was found to be linearly associated with poorer therapeutic alliances (Marmar, Weiss, & Gaston, 1989) and with poorer outcome (Horowitz, Marmar, Weiss, DeWitt, & Rosenbaum, 1984). Higher functioning patients did best with an emphasis on exploratory actions, whereas poorer functioning patients did best with supportive approaches. If simple counts are made independent of considerations of patient characteristic by process interactions, meaningful relationships are obscured. The value of certain therapist interventions may also vary as a function of the phase of therapy. Beck, Dugo, Eng, and Lewis (1986) described a multiphase model of the evolution of group process. Roles and tasks of the group leader and members vary as a function of the phase. Aggregation of process ratings without regard to phasic shifts obscure important relationships. In the field of brief dynamic psychotherapy process research (Sifneos, 1979; Malan, 1976; Mann, 1973), four phases were broadly defined: establishing a therapeutic alliance, defining a focus, working through a focal conflict, and termination. In the literature on brief psychotherapy of responses to traumatic life events (Horowitz, 1986; Marmar & Horowitz, 1988), a sequential model of phasic response to stress described progression from initial outcry, to denial and numbing, which yields to intrusion and working through, to completion. In the cognitive behavioral approaches to depression (Beck, Rush, Shaw, & Emery, 1979), sequential phases include the identification, challenging, and revision of pathogenic schemata. Despite the advances in theoretical and clinical specificity

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provided by these and related models, little attention has been paid in process research to defining interim phase and specific outcome criteria and to relating patient and therapist activities within phase to interim outcome criteria. The shift to a change episode, significant event, or phase paradigm holds great promise for unraveling the sequential dependencies and multidimensionality of process. Identification of critical events as recurring patterns increases the likelihood of a sophisticated reconstruction of the treatment process (Pinsof, 1986). Research on significant change episodes, however, introduces a new set of methodological challenges: (a) Can independent judges reliably agree on the occurrence of such episodes; (b) are such episodes idiosyncratic or generalizable across phases of therapies for an individual and across individuals within a treatment approach; and (c) ultimately are there critical change events that are generalizable across different modalities? A potentially fruitful direction for the field would be the development of a multi-user archive of reliably identified critical change events from different treatments. For example, such an archive might include prototypical instances of episodes of alteration in core conflictual relationship themes (Luborsky, Crits-Christoph, & Mellon, 1986), working states (Marmar, Wilner, & Horowitz, 1984), episodes of intrapersonal conflict resolution in gestalt therapy (Greenberg, 1983), significant change events identified by the Interpersonal Process Recall technique (Elliott, 1986), and tears and repairs in the therapeutic alliance (Bordin, 1979; Foreman & Marmar, 1985). Ideally, an archive of significant change episodes would include events associated with both progression and deterioration in the treatment process, the latter being somewhat underrepresented in this new approach. These identified, repetitive episodes would be the subject of research by investigators from diverse backgrounds allowing for comparison of theoretical and empirical modeling of the change process. Such an archive would also serve as a catalyst in the development of an integrative, generic theory of psychotherapy (Goldfried & Safran, 1986), permitting a test of the unique and general components across significant events in diverse therapies, and it would also contribute to the understanding of psychopathology.

Selection and Training of Judges Perhaps no single task in psychotherapy process research is more arduous than the recruitment and calibration of clinical judges. A host of factors, some of which are difficult to assess and control, can ultimately impact on the reliability and validity of ratings. The investigator's resources in terms of both time and funds available are often strained and may be disproportionately allocated to this difficult task. In selecting clinical judges, such issues as level of prior clinical experience and homogeneity of previous training of raters must be articulated with the nature, complexity, and degree of clinical inference required in the rating task. When the variables to be coded are closely anchored to observable features of the treatment process and when calibrated master ratings using clear examples are available, prior clinical training or personality characteristics of the rater are less likely to account for significant differences in process ratings. For example, Marmar, Wilner, and Horowitz (1984) compared the reliability of ad-

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vanced psychology and psychiatry trainees with beginning medical students in making determinations of patient states. Very detailed, case-specific training tapes were developed as state prototypes, and both sets of raters were trained to these video standards. Both groups subsequently achieved comparable, high reliability. Moras and Hill (1988) have made similar observations. In contrast, extensive experience in training judges on measures of the therapeutic alliance suggests that these ratings are sensitive to levels of clinical experience, theoretical orientation, extent and consistency of training procedures, frequency and quality of recalibration sessions, and coherence of the group process involved in being a member of a rating team (Marmar, Weiss, & Gaston, 1989). With regard to training judges, the general recommendations, with little in the way of empirical data to support these positions, include the following: (a) the development of detailed manuals with clear examples for both dimensions and levels within dimensions; (b) use of extensive transcripts or audiotape or videotape vignettes to serve as precalibrated master ratings; (c) extensive discussion for clarification of subtleties in the rating process; and (d) training to a preestablished criterion of reliability before initiating the formal rating task. Frequent recalibration sessions are often required during the rating task itself in order to maintain fidelity of the rating process. Recalibration at 2- to 3-week intervals has been recommended for ratings on the experiencing scales (Klein et al., 1986), a recommendation which was found to greatly enhance the quality of ratings of therapist and patient actions (Hoyt, Marmar, Horowitz, & Alvarez, 1981). A third factor that impacts on the reliability of clinical judgments concerns the ways in which psychotherapy process ratings are made, that is, the impact of such parameters of the rating task as observational medium, unit of analysis, and rating format. There has been considerable work on the impact of different rating strategies on the assessment of therapist interpersonal skills of accurate empathy, warmth, and genuineness (Beutler, Johnson, Neville, & Workman, 1973; Lambert, DeJulio, & Stein, 1978). These authors concluded that the manner in which ratings were gathered and subsequently analyzed had implications not only for reliability but also for the construct validity of the measures. McDaniel, Stiles, and McGaughey (1981) found that, in general, ratings made from transcripts yielded higher coefficients of agreement than those made from audiotapes. In studies of personality and psychopathology, with clear relevance to process research, Weiss (1979) found that judges' descriptions of personality traits were less differentiated when made from written materials than after personal contact with the subjects, and Waxer (1981) found that judgments of anxiety depended on nonverbal cues present in audio and video materials. In a systematic study of the effects on reliability of variations in the method of rating psychotherapy process (Weiss, Marmar, & Horowitz, 1988), five major rating parameters were subject to a complete five-way factorial analysis of variance. The process measure was the Therapist Action Checklist/Patient Action Checklist (Hoyt et al., 1981). The results were as follows: Ratings of patient actions were significantly more reliable than ratings of therapist actions; ratings made from videotapes yielded

greater reliability than those made from audiotapes; reliability of ratings varied as a function of the hour sampled; and ratings using a discrete tally system were more reliable than those coded with a global rating system. No effect on reliability was found when ratings on half-hour segments were compared with those on full sessions. Because of the complex dilemmas faced by the process researcher in selecting clinical judges, developing training protocols, and designing the rating task, further systematic study is required on the impact of these factors alone and in interaction on reliability and construct validity of process measures.

Conceptual Issues in Relating Process to Outcome The past decade has seen a converging interest on the part of both process and outcome researchers to study the relation between process and outcome (Bergin & Lambert, 1978; Greenberg & Pinsof, 1986; Rice & Greenberg, 1984). The view of process as limited to in-session activities and outcome as limited to extrasessional and posttreatment behavior has largely been abandoned. As a corollary, the field has given increasing attention to incremental outcomes in the course of therapy. Short-term within-session outcomes referred to as little o's are conceptualized as building toward termination and follow-up outcomes, which are designated as big O's. Attention to intermediary outcomes has led to diverse strategies for the assessment of outcome and treatment. Repeated-measure designs have been utilized in which the key (big O) dependent variables are measured at frequent intervals during treatment. These repeated measurement designs permit examination of dose-effect curves for treatment interventions (Howard, Kopta, Krause, & Orlinsky, 1986). Candidate measures for little o's are not limited to standard, measures of symptomatic, social functioning or personality change. The Mount Zion Psychotherapy Research Group (Sampson & Weiss, 1986) tested the effectiveness of therapist interventions by determining short-term shifts in depth of patient experiencing, boldness, and in-session anxiety. Using a similar strategy, Foreman and Marmar (1985) and Gaston, Marmar, and Ring (1989) examined the impact of therapist interventions on shifts in the treatment alliance. In these studies, traditional process variables are employed as short-term outcome criteria, supporting the view of Kiesler (1973) and others regarding the somewhat arbitrary distinction between process and outcome variables.

Data Analytic Issues Relating Process to Outcome Traditional aggregation or frequency count techniques have proven highly problematic in the study of the psychotherapeutic process. Experienced therapists take into account the multiple contextual factors that influence the decision to intervene in specific contexts and in specific sequences. For this reason, the wooden application of manualized techniques leads to a process that is insensitive to the individual needs of the patient, including momentary shifts in the capacity to confront affective material; changes in the status of the therapeutic alliance; nuances in coping and defense strategy; changes in extratherapy stress or social support that mediate the patient's ability to pro-

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SPECIAL SERIES: PROCESS RESEARCH

cess novel information in therapy; phase of treatment; and sequential ordering of prior interventions. Because interventions must be adjusted in relation to these contextual parameters, and because the impact of therapist interventions may occur at variable time intervals, a data analytic strategy is required to account for context and temporal sequencing of the treatment process. Apparently immediate negative impacts, such as emergence of negative affect following confrontation with loss, may be followed by more productive process in subsequent sessions and ultimately may be translated into new interpersonal capacities. The application of data analytic strategies that take into account the sequential dependency of process data have received increasing attention in the past decade (Gaston & Marmar, in press; Hill et al., 1983; Russell & Trull, 1986). Markov chain analysis has been applied by Benjamin (1979) to the study of dyadic interactions with the structural analysis of social behavior (SASB) and by Gottman (1979), who reported that dysfunctional couples seeking marital treatment entered into mutually criticizing cycles at the initiation of topic discussion. Lichtenberg and Hummel (1976) applied Markov chain modeling to initial interviews in an empirical study of counseling as a stochastic process. In their comprehensive review, Russell and Trull (1986) have documented progress in the application of Markov chain analysis, lag sequential analysis, and related sequential approaches. In their review, method advances were discussed, including the development of tests for significant differences among sequences to demonstrate changing patterns (Gottman, 1979), tests for cyclicity in interactions (Gottman, 1979; Allison & Liker, 1982), and the identification of latent structures in the sequential process (Dillon, Madden, & Kumar, 1983). Russell and Trull (1986) have distilled the major findings that have emerged from their review of studies applying sequential analyses of patient and therapist activities: Less controlling therapist interventions are related to greater patient openness and depth of exploration; deeper therapist interventions are more likely to be followed by greater patient resistance; better process results when clients are matched with role expectations; and therapists respond to patient hostility with avoidant responses. These results are impressive for their clinical salience, and challenge the view that psychotherapy process research yields findings that are not relevant to clinical practice. Although they advance the field of process research, sequential analytic approaches have important limitations. Elliott (1983), in a report to the National Institute of Mental Health sponsored psychotherapy process research workshop, suggested that sequential analyses have greater ability for testing a priori hypothesized sequences (e.g., client tests therapist, therapist passes test, client discloses previously warded off content) rather than for discovering previously identified episodes. Elliott (1983,1986) argues for the combination of qualitative and quantitative approaches for the identification and analysis of change episodes. Gaston and Marmar (in press) used a multiple time-series design to relate quantitative and qualitative approaches. The quantitative results suggested that meditation reduced symptoms of psoriasis. The qualitative findings provided stronger evidence in favor of the role of meditation and also suggested differential efficacy for an imagery technique. The

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qualitative approach also identified an unanticipated significant change event, the reduction of intrapsychic conflict. A strategy was proposed for moving iteratively between quantitative and qualitative approaches, with specific criteria borrowed from the field of single-case experimental designs proposed in moving toward a valid qualitative paradigm. A major data analytic challenge concerns strategies for determining the direction of influence among variables in process outcome predictions. Standard correlational approaches leave unanswered the question of the bidirectional influence of process outcome effects; for example, are the robust correlations of therapeutic alliance ratings with outcome the antecedents or consequences of gains in treatment? Patients who are improving are more likely to view their therapists as helpful and their treatment as relevant to their condition and as a consequence are more likely to commit to the treatment and engage in the therapist-offered strategies. Gottman and Markman (1978) and more recently Russell and Trull (1986) have recommended the use of sequential analytic approaches for assessing reciprocal influence processes. Gaston, Marmar, Gallagher, and Thompson (1989) have recommended a hierarchical, multiple regression analytic approach to address the potential bidirectional confound in process-outcome prediction. The sequence of predictors in their regression model was (a) initial pretreatment symptomatology, (b) in-treatment symptomatic change up to the point of alliance prediction, and (c) therapist and patient alliance ratings at that point in treatment. Alliance scores uniquely contributed to outcome over and above both initial symptomatology and in-treatment symptomatic change, supporting the role of the alliance as uniquely accounting for outcome variance. These sequential analytic and multiple regression strategies and related advances, including the application of covariance structure analysis (Kerwin, Howard, Maxwell, & Borkowski, 1987), represent an improvement over standard correlational approaches. They do not, however, permit a full test of the complex, multilayered pattern shifts that may occur at irregular intervals during the treatment process. In commenting on the limitations of these approaches, Russell and Trull (1986) noted: "Ultimately, we will need to develop nonlinear structural or field models of causality better fitted to the interactional and sequential complexities of psychotherapy" (p. 17).

Value of Comparative Outcome Studies for Psychotherapy Process Research Comparative outcome studies of psychotherapy present complex methodological challenges, are costly and time-consuming to mount, and, for the most part, have not yielded clear evidence of the superiority of specific psychosocial interventions for specific disorders. Furthermore, it is difficult for any one group to conduct a sequence of such trials in a programmatic effort to advance knowledge on differential efficacy. These findings point toward the potential value of intensive process studies embedded in clinical trials. Kazdin (1986) discussed three classes of variables that are relevant to process studies: parameter variables such as frequency and duration of sessions; treatment-specific interventions that vary qualitatively or quantitatively along specific dimensions; and depth of the therapeutic

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relationship. Kazdin recommended that the parameter variables be held constant in comparative trials, that the specific ingredients be defined and monitored for adherence, and that the relation and related variables be tracked for their potential impact on outcome. The domain of process variables that can be studied in this context is large and includes tests of differential therapist activities (DeRubeis, Hollon, Evans, & Bemis, 1982); fidelity or integrity of treatment, that is, the extent to which a treatment adheres to manualized definitions (Elkin, Parloff, Hadley, & Autry, 1985), and the quality or skillfulness of therapist interventions (Schaffer, 1983). A clinical trial of behavioral, cognitive, and brief dynamic psychotherapy for late-life depression (Thompson, Gallagher, & Breckenridge, 1987) provided the opportunity to examine the relations among patient pretreatment characteristics, process, and outcome. For the sample as a whole, a higher degree of patient defensiveness, as assessed before treatment, was related to poorer scores on patient commitment and working capacity dimensions of the therapeutic alliance (Gaston, et al., 1989). Therapist's alliance ratings of the patient commitment and patient working capacity factors were predictive of outcome, as were patient's alliance ratings on the patient commitment factor. When the relation between alliance and outcome was examined separately in the behavioral, cognitive, and brief dynamic therapy conditions, the strongest alliance outcome findings were for the cognitive therapy condition (Marmar, Gaston, Gallagher, & Thompson, 1989). In a study of tears and repairs in the alliance from this same clinical trial (Gaston, Marmar, & Ring, 1989), the greater the therapist and patient focus on patient's repetitive, maladaptive, interpersonal problems, the greater the likelihood of overcoming an initially poor therapeutic alliance and achieving a satisfactory outcome. These studies illustrate the economy achieved in comparative process studies embedded in clinical trials as well as the role of process research contributing to the understanding of differential efficacy.

sequential dependencies of process data and the interaction of process variables with pretreatment patient characteristics and that address the question of the bidirectional influence of process-outcome effects. Several strategies are offered that may enhance future research efforts. Promising new models of the levels of organization of process variables should be contrasted on shared data to assess their unique versus redundant contribution in modeling treatment. Greater attention to issues of dimensionality as well as convergent and discriminate validity of measures is required to ascertain what it is that process systems purport to measure. The development of outcome measures for achieving phase-specific treatment goals is likely to lead to a reconceptualization of more salient process variables. The use of already established process variables as very short-term outcome criteria for assessing impact of therapist interventions holds promise for building incremental models of treatment intervention. With regard to data analysis, the development of nonlinear structural or field models of causality will build on recent advances in sequential analysis. The development of a national archive of significant change events from different treatment modalities could serve as a vehicle for implementation of many of these future advances. It would permit a strong test of competing theoretical models, lead to advances in the segmentation dilemma, permit sophisticated studies of the construct validity of measures in the same and different domains, and serve as a springboard for advances in nonlinear structural models of causality. It also would serve as an ideal platform for advances in the integration of qualitative and quantitative approaches. It would hold the long-term potential for isolating the unique and common ingredients in the change process and would accelerate the development of a cross-theoretical language for the description of therapy process.

Conclusions and Directions for Future Work

Allison, P. D., & Liker, J. K. (1982). Analyzing sequential categorical data on dyadic interaction: A comment on Gottman. Psychological Bulletin, 91, 393-403. Beck, A. T., Rush, J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression: A treatment manual. New York: Guilford Press. Beck, A. P., Dugo, J. M., Eng, A. M, & Lewis, C. M. (1986). The search for phases in group development: Designating process analysis measures of group interaction. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 615-705). New York: Guilford Press. Benjamin, L. S. (1979). Use of structural analysis of social behavior (SASB) and Markov chains to study dyadic interactions. Journal of Abnormal Psychology, 88, 303-319. Bergin, A., & Lambert, M. (1978). The evaluation of therapeutic outcomes. S. Garfield & L. A. Bergin (Eds.), Handbook of psychotherapy and behavior change (pp. 139-189). New York: Wiley. Beutler, L. E., Johnson, D. T., Neville, C. W., Jr., & Workman, S. N. (1973). Some sources of variance in "accurate empathy" ratings. Journal of Consulting and Clinical Psychology, 40, 167-169. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252-260. Cashdan, S. (1973). Interactional psychotherapy: Stages and strategies in behavioral change. New York: Grune & Stratton.

The field of psychotherapy process research has grown increasingly sophisticated with the evolution of theoretical models of the treatment process, psychometric development, and data analytic strategies that are better articulated to the complex phenomenon under investigation. There is a growing consensus on the importance of segmentation of process by meaningful patterns wherever they may occur, in contrast with earlier unwarranted assumptions of the uniformity of process as reflected in more arbitrary sampling procedures and aggregating frequency approaches to data analysis. There are a number of promising efforts to model the multiple levels and dimensions of the treatment process and to reconstruct the process with ratings from multiple viewpoints on the relevant variables. The earlier tendency to view process and outcome as distinct domains of inquiry has been replaced by a focus on processoutcome relations and a reconceptualization of outcome-inprocess, which expands the domain of outcome to include intermediary and very short-term markers of change. There has been a shift from univariate correlational approaches to multivariate strategies that take into account the

References

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Psychotherapy process research: progress, dilemmas, and future directions.

The first several decades of psychotherapy process research have produced advances in measure development and substantive findings of process-outcome ...
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