How Psychotherapists Implement Research in Practice
Edited by
LOUIS G. CASTONGUAY, MICHAEL J. CONSTANTINO, AND LARRY E. BEUTLER
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Pour ma mere, Gemma, qui a construit des châteaux d’amour sur des échafauds de principes
(For my mother, Gemma, who has built castles of love on scaffolds of principles)
Louis G. Castonguay
For my graduate students and collaborators your support, inspiration, and dedication fuel my professional pursuits
Michael J. Constantino
For my many colleagues over the past 48 years who have collaborated with me, kept me on track, and informed me of what is real and important. I owe you this and much more. And to my wife Jamie who keeps me together and focused on our goals—bless her.
Larry E. Beutler
The three of us also dedicate this book to Abe Wolf, a man of principles, deep knowledge, clinical wisdom, and a most kind heart. We were honored to have Abe make substantial and insightful contributions to this project, even as he was fighting the recurrence of cancer. Sadly, Abe passed away as the book was going in press. We miss you, friend.
Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
Preface ix
About the Editors xiii
Advisory Board Members xv
Contributors xvii
PART I: INTRODUCTION
1. Implementing Evidence-Based Principles of Therapeutic Change: A Bidirectional Collaboration between Clinicians and Researchers 3 Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
2. An Updated List of Principles of Change That Work 13
Andrew A. McAleavey, Henry Xiao, Samantha L. Bernecker, Hannah Brunet, Nicholas R. Morrison, Mickey Stein, Soo Jeong Youn, Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
PART II: DEPRESSION
3. Depression Cases 41 Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
4. How I Would Apply Change Principles in Psychotherapy with Three Cases of Depression 57 Benjamin Johnson
5. Empirically Supported Principles of Psychotherapy 97 Abraham W. Wolf
6. Principles of Therapeutic Change in Treating Depression with an Integrative Application of the Cognitive Behavioral Analysis System of Psychotherapy 129 Dina Vivian
7. Conceptual, Clinical, and Empirical Perspectives on Principles of Change for Depression 167 Benjamin Johnson, Dina Vivian, Abraham W. Wolf, Larry E. Beutler, Louis G. Castonguay, and Michael J. Constantino
PART III: ANXIETY DISORDERS
8. Anxiety Disorders Cases 215
Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
9. Principles of Therapeutic Change: A Psychoanalyst’s Perspective 231 Eva D. Papiasvili
10. A Cognitive-Behaviorist’s Report from the Trenches 269 Catherine S. Spayd
11. More Than a Feeling? Application of Principles of Change to Treatment of Anxiety 299 Igor Weinberg
12. Conceptual, Clinical, and Empirical Perspectives on Principles of Change for Anxiety Disorders
Eva D. Papiasvili, Catherine S. Spayd, Igor Weinberg, Larry E. Beutler, Louis G. Castonguay, and Michael J. Constantino
PART IV: CONCLUSION
325
13. Harvesting the Fruits of a Clinician-Researcher Collaboration and Planting Seeds for New Partnerships 365
Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
Preface
“You want to know how to become a good therapist? First and foremost, you have to master techniques of treatment protocols that have been found effective in randomized clinical trials.”
“How does therapy work? The bottom line: It’s all about the therapeutic relationship.”
“Techniques? Relationship? Who are we kidding? What really matters is whether the client wants and can change.”
It is these kind of comments, frequently heard at conferences and professional gatherings, that led two of us, LGC and LEB, to create a task force in the early 2000s to give credence to an absolutely “brilliant” idea of ours: “Therapeutic change might not be entirely explained by either one of these variables alone; it is more likely related to a complex combination of technical, relational, and participant factors.” Brilliant and earth shattering, right? To demonstrate our point (which, of course, was by no mean an original one), we invited 12 groups of influential scholars to review the research literature on the role of these three types of factors in the treatment of diverse clinical problems. From these reviews, we also asked them to derive principles of change that could inform therapists from different theoretical orientations. This led to our book, Principles of Change That Work, which Oxford University Press (OUP) published in 2006.
When we were approached to edit a sequel to that book, we agreed—but only under the conditions that we would not do it alone and that the second volume would be more than an updated version of the first one. Rather, we (a trio that now included MJC) wanted to improve the list of principles that resulted from the first book by conducting a new and uniform review of the research and, most important, by addressing the major criticism (as painful to hear as it was fair) that had been voiced about the first volume: “The book tells me what are some of the principles that are linked to outcome, but it does not inform me about how to use them in my day-to-day practice.”
We were fortunate to have Andrea Zekus and Sarah Harrington, both at OUP, endorse our self-imposed ambitious goals. As described in the first chapter of the present volume, we have tackled these goals by having graduate students complete a major review of empirical literature and by having six
expert clinicians describe, in rich and engaging detail, the implementation of the 38 principles of change that were retained from the review.
By illustrating how, when, and with whom these principles are applied in different treatment approaches, the current book not only addresses a valid critique of the first one, but it also highlights the unique expertise of professionals who are participating in and observing psychotherapy as it is routinely practiced. The book also provides an opportunity for practitioners to delineate convergences and divergences in the implementation of principles, express opinions regarding their clinical helpfulness and validity, and make suggestions for future revisions and research regarding these principles. Ultimately, by presenting complementary knowledge (what do we know about empirically about principles of change, and what are ways to implement them clinically?) and by fostering exchanges between clinicians and researchers, our hope is that this book offers a fresh, broad, and integrative perspective on evidence-based practice.
For allowing us to pursue this collaborative project, we want to thank Sarah and Andrea, not only for their vote of confidence but also for their support and patience. We also want to express our gratitude to Hayley Singer for her help throughout the final phase of publication, as well as to Patricia Santoso for given us permission to use her beautiful art on the cover of our book. We are most grateful for the lengthy literature review conducted by outstanding earlycareer scientists-practitioners: Samantha Bernecker, Hannah Brunet, Andrew McAleavey, Nicholas Morrison, Mickey Stein, Henry Xiao, and Soo Jeong Youn. A special “thank you” to Andrew, who coordinated this review, as well as to Henry, who aggregated and organized its findings.
We are also thankful to friends on our advisor board: Barry Farber, Charles Gelso, Marvin Goldfried, Gary Groth-Marnat, Laurie Heatherington, Hanna Levenson, Phillip Levendusky, and Heidi Levitt. Their advice has allowed us to recruit exemplary clinicians willing to write about the complex relationship between scientific findings and clinical realities. Our deepest gratitude goes to these authors—six highly gifted and experienced practitioners/ scholars: Benjamin Johnson, Eva Papiasvili, Catherine Spayd, Dina Vivian, Igor Weinberg, and Abraham Wolf. We greatly appreciate the time and wisdom they provided in completing each of the many tasks that we asked them to contribute, let alone the kindness and collaborative spirit that they demonstrated in dealing with many waves of feedback and revisions. We are not only grateful
Preface xi
for their bold and elegant chapters but also humbled for how much we learned from the insightful, nuanced, and creative ways they each conduct and think about psychotherapy.
Louis G. Castonguay, PhD State College, Pennsylvania
Michael J. Constantino, PhD Northampton, Massachusetts
Larry E. Beutler, PhD, ABPP El Dorado Hills, California
About the Editors
Louis G. Castonguay, PhD, completed his doctorate in Clinical Psychology at SUNY–Stony Brook, a clinical internship at UC Berkeley, and a postdoctorate at Stanford University. He is currently a Liberal Arts Professor of Psychology at Penn State University. With more than 200 publications (including nine coedited books), his scholarly work and research focus on different aspects of the therapeutic change and training (including variables related to interventions, relationship, client, and therapist), especially within the context of psychotherapy integration. He is also involved in practice-oriented research and the development of Practice Research Networks, both aimed at facilitating the collaboration between clinicians and researchers. In addition, he has been investigating the process and efficacy of new integrative treatments for generalized anxiety disorder and depression. He has received several recognitions, including Distinguished Awards for his lifetime contributions from both the Division of Psychotherapy of the American Psychological Association and the Society for Psychotherapy Research (SPR). He also served as president of SPR and the the North American chapter of SPR.
Michael J. Constantino, PhD, completed his doctoral training in Clinical Psychology at the Pennsylvania State University, a clinical internship at SUNY–Upstate Medical University, and a postdoctoral fellowship at the Stanford University Medical Center. Dr. Constantino is currently a professor in the Department of Psychological and Brain Sciences at the University of Massachusetts–Amherst, where he directs the Psychotherapy Research Lab and serves as Graduate Program Director. Dr. Constantino’s professional and research interests center on patient, therapist, and dyadic factors in psychosocial treatments; pantheoretical principles of clinical change (i.e., common factors); and measurement-based care. He has authored or co-authored over 140 journal articles and book chapters and over 220 professional presentations. Dr. Constantino’s work has been recognized internationally, including with his receipt of the American Psychological Foundation’s Early Career Award, the Society for the Exploration of Psychotherapy Integration’s New Researcher Award, the Society for Psychotherapy Research’s Outstanding Early Career Achievement Award, the American Psychological Association (APA) Division 29 (Society for the Advancement of Psychotherapy) Distinguished Publication of Psychotherapy Research Award, and APA and Division 29 fellow status.
Dr. Constantino is president of APA Division 29 and past president of the North American Society for Psychotherapy Research.
Larry E. Beutler, PhD, is the past Director of the National Center on the Psychology of Terrorism, a multicenter institute sponsored by Stanford University, Palo Alto University, and the Palo Alto Veterans Health Care System. He is the William McInnes Distinguished Professor Emeritus and the former Chair and Director of Training for the Clinical Psychology Program at Palo Alto University’s Pacific Graduate School of Psychology in Palo Alto, California. He also holds an appointment as Professor Emeritus at the University of California–Santa Barbara where he established and directed the Clinical/Counseling/School Psychology Program. Dr. Beutler’s first positions following his graduation (PhD, Clinical Psychology) from the University of Nebraska–Lincoln (1970) was at Duke University Medical School. This placement was followed by appointments at Stephen F. Austin State University, Baylor College of Medicine, and the University of Arizona. Subsequently, he moved to California. Dr. Beutler is a Diplomate of the American Board of Professional Psychology (ABPP), a two-term past international president of the Society for Psychotherapy Research (SPR), past president of the Society for Clinical Psychology (Division 12, APA), and past president of the Division of Psychotherapy (American Psychological Association, Division 29). He is a recipient of the Distinguished Scientific Achievement Award from the California Psychological Association, the Distinguished Research Career Award from the Society for Psychotherapy Research, International, and a Presidential Citation from the president of the American Psychological Association.
Advisory Board Members
Barry A. Farber, PhD
Charles J. Gelso, PhD
Marvin R. Goldfried, PhD
Gary Groth-Marnat, PhD
Laurie Heatherington, PhD
Hanna Levenson, PhD
Phillip G. Levendusky, PhD
Heidi M. Levitt, PhD
Contributors
Samantha L. Bernecker, PhD Department of Psychology
Harvard University
Larry E. Beutler, PhD, ABPP Department of Clinical Psychology
Palo Alto University
Hannah Brunet, PhD Neurological Institute
Cleveland Clinic Lou Ruvo Center for Brain Health
Louis G. Castonguay, PhD Department of Psychology
The Pennsylvania State University
Michael J. Constantino, PhD Department of Psychological and Brain Sciences
University of Massachusetts Amherst
Benjamin Johnson, PhD, ABPP
The Warren Alpert Medical School of Brown University
Rhode Island Center for Cognitive Behavioral Therapy
Andrew A. McAleavey, PhD Department of Psychiatry
Weill Cornell Medicine
Nicholas R. Morrison, MS
Department of Psychological and Brain Sciences
University of Massachusetts Amherst
Eva D. Papiasvili, PhD, ABPP Department of Clinical Psychology Teachers College, Columbia University
Institute of the Postgraduate Psychoanalytic Society, New York
Catherine S. Spayd, PhD Private practice Duncansville, Pennsylvania
Mickey Stein, PhD Clinical Psychologist Back In Motion
Vancouver, Canada
Dina Vivian, PhD Department of Psychology
Stony Brook University
Igor Weinberg, PhD Department of Psychiatry
Harvard Medical School
Abraham W. Wolf, PhD Department of Psychiatry
Case Western Reserve University
Henry Xiao, MS Department of Psychology
The Pennsylvania State University
Soo Jeong Youn, PhD Department of Psychiatry
Massachusetts General Hospital/ Harvard Medical School
PART I INTRODUCTION
1
Implementing Evidence-Based Principles of Therapeutic Change
A Bidirectional Collaboration between Clinicians and Researchers
Louis G. Castonguay, Michael J. Constantino, and Larry E. Beutler
It is well recognized that the links between psychotherapy research and practice are tenuous. This can be attributed, in part, to limited active collaboration and direct communication between researchers and clinicians (Beutler, Williams, Wakefield, & Entwhistle, 1995; Castonguay, Barkham, Lutz, & McAleavey, 2013; McWilliams, 2017). Researchers and practitioners comprise different communities, and their communication pattern largely follows a one-way street (Castonguay, 2011). To avoid perishing, researchers are driven to publish their studies in peer-reviewed scientific journals. Working from the assumption that one function of such journals is to disseminate research results to varied psychotherapy communities, many researchers trust (or at least hope) that clinicians will read these articles and apply the findings to their practice.
However, because of space limitations and an emphasis on methodological details, recommendations about how results can influence practice tend to be brief and unelaborated in most research outlets. Furthermore, because researchers are the ones who, by and large, generate such implications, clinicians may find them as having limited applicability to their practice. Finally, although some data suggest that clinicians find research useful (Beutler et al., 1995), they also report that empirical journals are not their primary source for guiding their clinical practice (e.g., Cohen, Sargent, & Sechrest, 1986; Morrow-Bradley & Elliott, 1986). This finding holds even for clinicians who also conduct research (Safran, Abreu, Ogilvie, & DeMaria, 2011). Thus, the current system for disseminating and applying evidence to practice remains prone to a wide clinician–researcher chasm.
To address this gap, several efforts have been made to describe how research findings, especially when presented without jargon, can be relevant to day-to-day practice (e.g., Castonguay et al., 2010; Cooper, 2008). Although such efforts likely provide useful information to therapists, they nevertheless represent a type of “empirical imperialism” whereby researchers, who generally treat few clients, try to instruct therapists, who treat many, on issues worthy of scientific attention and on the lessons that can be derived from research findings (Castonguay, 2011). In the extreme, this amounts to researchers telling therapists what they should want to know and what they should do, which is hardly an effective way to reduce the research–practice gap.
This top–down approach to the accumulation and dissemination of research evidence has had negative ramifications for the field. As Garland, Hulburt, and Hawley (2006) argued, “clinicians feel disenfranchised by researchers, believing that research often disregards their realities and invalidates their experience as professionals” (p. 32). This subjective experience of practitioners is not without basis. In a survey of both clinicians and researchers, Beutler et al. (1995) found that clinicians reported research as being important more than researchers reported the clinical literature as being important. By not fully recognizing clinicians’ perspectives, the psychotherapy research field may have suffered from developmental delays and/or myopic impairment in its effort to understand and improve therapeutic change. As Kazdin (2008) aptly noted, “we are letting the knowledge from practice drip through the holes of a colander” (p. 155). Far from being intrinsically irreconcilable with research findings, we argue that the ideas and observations of many clinicians about psychotherapy (how change is facilitated or hampered, with whom and by whom) can shed light on how research evidence can best be implemented and on what issues should be studied to increase the effectiveness of psychotherapy. We concur with Beutler et al.: “Scientists may be missing important avenues for identifying critical areas of research. They may do a better scientific job if they were more attentive to the writings and ideas of their clinical colleagues” (pp. 989–990).
Goals of the Book
The present book builds on a previous volume, Principles of Therapeutic Change that Work (Castonguay & Beutler, 2006), and represents a new collaboration based on direct, two-way communication between researchers and clinicians that relies on their respective and overlapping knowledge and expertise. To us, this synergy holds promise for increasing our understanding and improving
our delivery of psychotherapy. Blending knowledge from these sources, however, requires that we acknowledge that psychotherapy is more complex than applying a standard and sequenced package of interventions to classes of clients, with the assumption that these interventions are, above anything else, the primary factors responsible for therapeutic improvement. This assumption, which underlies the method of studying psychotherapy through randomized clinical trials (RCTs) is dated at best and naïve at worst. Whereas comparative RCTs narrowly privilege the contributions of the client’s diagnosis and the therapeutic model, a broader evidence-informed and integrative view of psychotherapy emphasizes client factors beyond diagnoses, therapist factors (including between-therapist effects), dyadic processes, and the need to personalize treatment to individuals and contexts (Constantino, Coyne, & Gomez Penedo, 2017). Guided by such an integrative view, this volume is an attempt to create a new avenue toward evidence-based practice that relies on clinicians as active collaborators, rather than as passive recipients, in understanding and implementing research findings.
Castonguay and Beutler’s (2006) first volume integrated, in broad brush strokes, research findings on factors that contribute to client improvement either directly (e.g., predictors) or in interaction (e.g., client trait × treatment effects). Influential psychotherapy scholars worked in teams (most of which comprised researchers of different theoretical orientations) to review research on three variable domains (participant characteristics, relationship variables, technical/intervention factors) as they applied to one particular type of clinical problem (dysphoric disorders, anxiety disorders, personality problems, substance use disorders). In addition, the authors translated the research evidence into principles of change that could serve as helpful clinical guidelines without being tied to particular jargon or theoretical models. The work of these 12 teams led to an aggregated list of 61 principles of change.
Although this initial volume succeeded in delineating change principles that cut across different theoretical orientations, we have since determined that it did not adequately inform clinicians (as stated by a review on amazon. com, as well as in comments made to the editors/authors at various conferences) in how to apply them. Accordingly, we restructured the present followup volume. Specifically, we (a) provided detailed descriptions of the ways in which empirically based principles of change might be effectively and efficiently implemented within and across major contemporary psychotherapies, (b) gave a direct voice to practicing clinicians by having them describe how, when, and with whom they apply (or do not apply) these principles in their clinical practice, and (c) sought to provide clinicians and researchers with opportunities to link collaboratively clinical knowledge and the empirical literature.
Structure of the Book
The book contains four major sections. The first section provides a general overview of the book (current chapter) and presents a revised list of the 61 principles of change that were delineated in the first volume (Chapter 2). The second chapter also describes the process that led to the revised list that regroups principles into five conceptually cohesive and clinically relevant clusters: client prognostic principles, treatment/provider moderating principles, client process principles, therapy relationship principles, and therapist interventions principles.
The second and third sections of the book focus on depression and anxiety disorders, respectively. We decided not to have specific sections on personality and substance use disorders (the other two disorders covered in the first volume) because relatively few clients come to treatment primarily for these disorders (at least in most practices). However, we still emphasize these clinical problems in the current volume. Specifically, both sections on depression and anxiety begin with a brief chapter (Chapters 3 and 8, respectively), written by the editors, presenting three cases: one with co-morbid substance abuse, one with co-morbid personality disorder, and one without substanceabuse or personality disorder co-morbidity. The cases also incorporate clinical features frequently associated with depression or anxiety (e.g., marital, occupational, health problems). We created these vignettes to provide a range of clinical situations for practitioners to describe when and how different principles of change may be applicable in their work.
The core of both sections on depression and anxiety are three additional chapters (Chapters 4, 5, and 6, and 9, 10, and 11, respectively) written by the contributing clinicians. The clinicians represent different blends of insightoriented, or exploratory, and behavior change-oriented approaches. In preparing this book, we decided not to select clinicians representing “pure” forms of therapy, as relatively few therapists define themselves as exclusively cognitive-behavioral, psychodynamic, humanistic, or systemic. To inform their chapter, the clinicians were provided with the revised list of principles and asked to describe how they might use these principles in their work with each of the three clinical cases in their assigned section (depression or anxiety). As described more fully in the following discussion, we invited the authors to explain in detail how they might apply the principles and to think through (out loud, so to speak) their reasoning behind such implementation (or lack thereof).
The depression and anxiety sections both end with a chapter (Chapters 7 and 12, respectively) co-written by the clinician authors and the editors. The first goal of these chapters is to identify convergences and divergences with
respect to how therapists work with empirically based principles. Moreover, these chapters examine therapists’ perception of the clinical helpfulness and validity of these principles, as well as their ideas regarding possible combinations of separate principles. Also provided are directions for future research based on principles generated by the clinicians and discrepancies between the current empirical data and some of the therapists’ perspectives. Final thoughts are then presented, with an emphasis given to the implications of principles regarding therapist effects (to help understand why some therapists are better than others) and training.
The fourth and final section of the book is a concluding chapter (Chapter 13) written by the editors that summarizes the tasks that were completed, the results that were achieved, and the experience of clinicians and researchers involved in this collaborative project. Suggestions are also offered to enhance our conceptual understanding of principles of change, as well as foster partnerships between clinicians and researchers to examine their validity and impact in dayto-day clinical routine.
Selection of Clinicians
Several criteria guided our selection of the clinical authors who served as proxies for therapists sharing their clinical perspectives and approaches to psychotherapy. First, we invited clinicians who represented a variety of theoretical orientations. To quantify these differences and to ensure diversity, we assessed potential authors’ orientation with a brief self-report version of the Therapy Process Rating Scale (TPRS; Kimpara, Regner, Usami, & Beutler, 2015). In addition, the selection criteria included (a) having been trained in accredited graduate or postgraduate mental health programs; (b) having been involved in at least half-time clinical practice for at least two years; (c) recognizing the value of evidence-based and integrative practice, including different types of quantitative and qualitative research; and (d) having previous writing experience, as first author or co-author of professional publications.
To create a pool of potential authors, we drew on our own knowledge of clinicians and created an advisory board of reputable scholars and/or clinicians in the field. Advisory board members were selected based on the following criteria: (a) being known for their publications on the conduct and/or training of psychotherapy; (b) having trained and supervised many clinicians for several years; (c) having maintained a clinical practice for several years; (d) valuing the contributions of a diversity of theoretical orientations (even if being viewed by many in the field as an influential figure of a particular approach);
