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Psychotherapy - Vol 54, Iss 3

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Psychotherapy Theory, Research, Practice, Training Psychotherapy: Theory, Research, Practice, Training publishes a wide variety of articles relevant to the field of psychotherapy. We strive to foster interactions among training, practice, theory, and research because all are essential to psychotherapy.
Copyright 2017 American Psychological Association
  • Behavioral activation as a common mechanism of change across different orientations and disorders.
    Behavioral activation is an effective treatment for depression, based on targeting deprivation of positive rewards. It becomes more and more evident that many forms of mental disorders and psychological suffering involve reduction of goal-driven and pleasant activities. This reduction leaves negative mental states free to take the center of consciousness, without being counterbalanced by positive feelings, memories, and experiences of agency, self-efficacy, competence, relaxation, energy, and satisfaction. Reduced activity can be found in disorders ranging from chronic pain to personality disorders and schizophrenia. We believed that the time was ripe to reason that behavioral activation, more than a treatment in itself, can be considered a fundamental mechanism of change in the psychotherapy for a wide range of dysfunctions, irrespective of the clinician’s preferred orientation. In this special section, authors from diverse orientations describe how they integrate behavioral activation in their clinical practice, while providing rich and detailed clinical illustrations. We reflect that behavioral activation needs to be implemented in many forms of psychotherapy and for a wide range of disorders. Moreover, it has the potential to make treatment faster and maximize outcomes, as long as it is delivered under careful consideration of the therapy relationship. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Behavioral activation strategies for major depression in transdiagnostic cognitive-behavioral therapy: An evidence-based case study.
    Behavioral activation (BA) is a treatment approach that uses functional analysis and context-dependent strategies to enhance environmental positive reinforcement for adaptive, healthy behavior, and decrease behavioral avoidance. BA has gained considerable support for the treatment of depression and can be broadly applied across a wide range of settings and clinical populations. In this article, we provide a brief description of BA as a therapeutic behavioral strategy for depression and present a clinical case example illustrating the integration of BA with other components of a transdiagnostic cognitive–behavioral treatment for emotional disorders. Implications for clinical practice and avenues for future research will be discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders.
    Considerable work and attention has supported the use of behavioral activation (BA) strategies in the treatment of depressive disorders. Although not often recognized, BA, both implicitly and explicitly, appears to be conceptually and empirically relevant to the treatment of diverse problem areas, including the anxiety disorders. This article addresses the role of BA strategies in transdiagnostic cognitive–behavioral therapy (CBT) for anxiety and related disorders, including in cases without comorbid depression. Following a brief introduction to a transdiagnostic CBT model of anxiety and related disorders, this article will: (a) provide a rationale for the integration of BA strategies as a potentially potent facilitator of therapeutic change; (b) identify relevant treatment targets of BA in anxiety disorders; and (c) illustrate the implementation and impacts of these strategies using a clinical case example. Finally, suggestions for future research and implications for training and practice will be noted. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Adaptation of behavioral activation in the treatment of chronic pain.
    Chronic pain is a common problem that can be challenging to treat because of its complex history, unclear etiology, and poor response to traditional treatment approaches. A growing body of research suggests that behavioral activation (BA), which was originally developed as a treatment for depression, may be a promising treatment for chronic pain. BA involves the identification and enactment of activities that are reinforcing to the individual and consistent with his or her long-term goals. The application of BA for the treatment of chronic pain is fully consistent with models of chronic pain which post that fear and avoidance leads to a cycle of physical deconditioning, increased pain as a result of deconditioning, lack of positive reinforcement, and low mood, and further reduced motivation to physically engage. The present paper will detail the assessment and use of BA to treat “Veteran,” a patient with low back and bilateral foot pain. This case study highlights how gradually increasing engagement in previously avoided activities can help disrupt the harmful cycle among pain, fear and avoidance, and mood. The implication of the outcomes from this case study for future psychotherapy research on chronic pain is also discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Agency before action: The application of behavioral activation in psychotherapy with persons with psychosis.
    Incorporating behavioral activation into psychotherapy with persons with psychosis requires adaptation in its conceptualization and application owing to special deficits in the self-experience. Persons with psychosis often experience a diminished or disorganized sense of self, and have deficits in coherently narrating the experience of the self and in the ability to make sense of how to take action and direct their own lives. Based on a metacognitive model of disability in psychosis, the current paper presents a therapy process of a woman coping with schizophrenia using Metacognitive Reflection and Insight Therapy (Lysaker and Dimaggio, 2014) in the framework of an intersubjective model for psychotherapy with persons with psychosis presented by Hasson-Ohayon, Kravetz, and Lysaker (2016a). The case in point and its following discussion highlight the important significance of metacognitive encouragement as a first step of behavioral activation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Behavioral activation in the treatment of metacognitive dysfunctions in inhibited-type personality disorders.
    Behavioral interventions are proposed as a critical treatment component in psychotherapy for personality disorders. The current study explores behavioral interventions as a mechanism of change in Metacognitive Interpersonal Therapy, an integrative psychotherapy for personality disorders. The goals and implementation of behavioral principles are illustrated through the single case study of Roger, a 57-year-old man diagnosed with avoidant personality disorder and depressive personality disorder. Transcripts of interviews and therapy sessions illustrate the role of behavioral interventions, including behavioral activation, in Roger’s treatment. Roger demonstrated a reliable change from baseline to posttreatment across all measures. He also showed gains with regard to his occupational functioning, interpersonal relationships, and sense of fulfilment. Implications with regard to treatment planning for personality disorders are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Behavioral activation in TFP: The role of the treatment contract in transference-focused psychotherapy.
    Transference-focused psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. Similar to other psychodynamic psychotherapies, TFP focuses on changing psychological structures, but also focuses on symptom and behavioral change, particularly the importance of being active (e.g., obtaining a job or involvement in similar activities). In TFP, the establishment of the treatment contract, also known as the treatment frame, is where goals such as work and other activities are agreed upon. The focus on such activities is particularly relevant to the concept of behavioral activation. We provide a clinical vignette to illustrate how TFP utilizes behavioral activation in facilitating treatment outcome both at the behavioral level and at the psychological level. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Psychodynamizing and existentializing cognitive–behavioral interventions: The case of behavioral activation (BA).
    From the point of view of Cognitive–Existential Psychodynamics (Shahar, 2015a, 2016; Shahar & Schiller, 2016; Ziv-Beiman & Shahar, 2016), active techniques—primarily cognitive–behavioral therapy ones—might not only reduce distress but also bolster the therapeutic relationships and serve as powerful vehicles for self-discovery and growth. This, however, is contingent upon therapists’ ability to view, and present to patients, the psychodynamic and existential nature of active techniques. Our focus herein is on behavioral activation, an intervention that consists of encouraging patients to participate in enjoyable and meaningful activities, in the face of depressive anhedonia. We posit that psychodynamizing and existentializing behavioral activation has the potential to increase awareness of inner multiplicity, strengthen eco-functions, assist in creating a “holding environment,” bolster responsibility through agency, and offer a sense of transcendence. These benefits of behavioral activation are illustrated via a clinical case. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Process factors explaining psycho-social outcomes in adventure therapy.
    The development and factor analysis of the Adventure Therapy Experience Scale (ATES) is the first attempt found in the literature to empirically and quantitatively identify therapeutic factors theorized to affect change in the adventure therapy experience (Russell & Gillis, 2017). This study utilizes the ATES to explore how its inherent factors may impact treatment outcome utilizing a routine outcome monitoring process to empirically test how these factors may contribute to treatment outcome over time. The sample of 168 males 21.5 years of age completed an average of 79.6 days in the 90-day adventure-based substance use disorder residential treatment program. In the model, adventure-based experiences are a primary treatment tool. For outcome monitoring, all clients were administered the Outcome Questionnaire (OQ-45.2) at intake, every 2 weeks, and at discharge. In addition, clients were administered the 18-item ATES every 2 weeks. The ATES contains 2 items measuring how helpful the adventure experience was as well as how mindful they were of their treatment process during the experience. Clients also answer 16 Likert items measuring responses on 4 subscales: group adventure, nature, challenge, and reflection. Results reveal that clients, on average, improved in their psycho-social functioning as measured by the OQ 45.2. Weeks with higher helpfulness, mindfulness, and group adventure scores than the client’s average helpfulness, mindfulness, and group adventure score, had greater decreases in OQ scores than weeks with lower helpfulness, mindfulness, and group adventure scores. Clients with higher aggregate helpfulness and group adventure scores, across all treatment weeks, had greater decreases in OQ scores than clients with lower aggregate helpfulness and group adventure scores. Implications for practice and future research are also discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Attachment-based family therapy and individual emotion-focused therapy for unresolved anger: Qualitative analysis of treatment outcomes and change processes.
    Twenty-six clients who received 10 sessions of either attachment-based family therapy (ABFT) or individual emotion-focused therapy (EFT) for unresolved anger toward a parent were interviewed 6 months after completing treatment. Interviews were analyzed using the consensual qualitative research approach. Clients in both conditions reported improved relationships with parents, gaining a new perspective of their parent, increased compassion toward parent, less reactivity to anger, feeling cleaned-out, and acquiring new coping strategies. Whereas ABFT clients more often reported improved relationships with parents, EFT clients more often reported feeling cleaned-out. Clients in both groups attributed change to productive emotional processing. Also, clients in both groups attributed change to saying difficult things that had never been said before directly to parents, though more so in ABFT. Whereas ABFT clients noted the importance of their parents participating in treatment and mutual vulnerability, EFT clients noted the importance of remembering previously avoided memories and feelings, and getting their anger of their chest. While some EFT clients reported that therapy had a negative impact on their relationship with their parents and increased their anger, some ABFT clients reported that the positive impact of therapy during the active phase of treatment did not last, though there were no meaningful between-groups differences regarding these negative treatment outcomes and processes. Results are discussed in the context of previous quantitative findings from the same sample, and in the context of prior research on experiential and emotion-focused therapies. Implications for future research are noted. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Crying in psychotherapy: The perspective of therapists and clients.
    Eighteen U.S.-based doctoral students in counseling or clinical psychology were interviewed by phone regarding experiences of crying in therapy. Specifically, they described crying as therapists with their clients, as clients with their therapists, and experiences when their therapists cried in the participants’ therapy. Data were analyzed using consensual qualitative research. When crying with their clients, therapists expressed concern about the appropriateness/impact of crying, cried only briefly and because they felt an empathic connection with their clients, thought that the crying strengthened the relationship, discussed the event with their supervisor, and wished they had discussed the event more fully with clients. Crying as clients was triggered by discussing distressing personal events, was accompanied by a mixture of emotions regarding the tears, consisted of substantial crying to express pain or sadness, and led to multiple benefits (enhanced therapy relationship, deeper therapy, and insight). When their therapists cried, the crying was brief, was triggered by discussions of termination, arose from therapists’ empathic connection with participants, and strengthened the therapy relationship. Implications for research, training, and practice are presented. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • The development and initial validation of the Countertransference Management Scale.
    Countertransference is an important aspect of the therapeutic relationship that exists in therapies of all theoretical orientations, and depending on how it is managed, it can either help or hinder treatment. Management of countertransference has been measured almost exclusively with the Countertransference Factors Inventory (Van Wagoner, Gelso, Hayes, & Diemer, 1991) and its variations, all of which focus on 5 therapist qualities theorized to facilitate management: self-insight, conceptualizing ability, empathy, self-integration, and anxiety management. Existing versions of the Countertransference Factors Inventory, however, possess certain psychometric limitations that appear to constrain how well they assess actual management of countertransference during a therapy session. We thus sought to develop a new measure that addressed these limitations and that captured the 5 therapist qualities as constituents (rather than correlates) of countertransference management that manifest in the treatment hour. The development and initial validation of the resulting 22-item Countertransference Management Scale (CMS) is described here. Exploratory factor analysis of ratings of 286 therapy supervisors of current supervisees indicated that the 5 constituents of countertransference management could be grouped into 2 correlated factors: “Understanding Self and Client” and “Self-Integration and Regulation.” Evidence of convergent and criterion-related validity was supported by CMS total and subscale scores correlating as expected with measures of theoretically relevant constructs, namely, therapist countertransference behavior, theoretical framework, self-esteem, observing ego, empathic understanding, and tolerance of anxiety. Results also supported the internal consistency of the CMS and its subscales. Research, clinical, and training implications are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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