a comparative analysis of the therapeutic focus in cognitive behavioral and psycho dynamic...

8/8/2019 A Comparative Analysis of the Therapeutic Focus in Cognitive Behavioral and Psycho Dynamic Interpersonal Sessio

1/9

Journal of Consulting and Clinical Psychology Copyright 1997 by the American Psychological Association, Inc.1997, Vol. 65, No. 5, 740- 748 0022-006X/97/$3.00

A Comparative Analysis of the Therapeutic Focus in Cognitive-Behavioral and Psychodynamic-Interpersonal SessionsMarvin R. GoldfriedState University of New York at Stony Brook Louis G. CastonguayPennsylvania State University

Adele M. HayesUniversity of Miami John E Drozdstate University of New York at Stony BrookDavid A. ShapiroUniversity of Leeds

This study compared therapeutic foci in a sampling of 30 cognitive-behavioral and 27 psychody-namic-interpersonal manual-driven reatments for depression. High- and low-impact sessions werecoded for each client, with the Coding System of Therapeutic Focus. Results indicated that psychody-namic-interpersonal sessions focused more on such variables as emotion, patterns, incongruities,the impact that others made on clients, clients' expected reaction of others, the tendency to avoidtherapeutic progress, therapists themselves, clients' parents, and links between people and timeperiods in clients' lives. Cognitive-behavioral sessions placed greater emphasis on external circum-stances and clients' ability to make decisions, gave more support and information and encouragedbetween-session experiences, and focused more on the future. Relatively few differences emergedas a function of session impact. Results are discussed in terms of the different and similar theoreticalconceptions of the change process.

Despite the growing cli nical interest in psychotherapy integra-tion, there has been surprisingly little research to provide empir-ical underpinning s for this movement (Arnkoff & Glass, 1992;Castonguay & Goldfried, 1994; Goldfried, 1991; Stricker, 1994;Wolfe & Goldfried, 1988). Recognizing the need for empiricalresearch, a National Institute of Mental Health (NIMH) Confer-ence on Psychotherapy Integration provided some potential di-rections for future research. Among these was the suggestionthat, before conducting controlled outcome research to compare

Marvin R. Goldfried and John F. Drozd, Department of Psychology,State Universityof New York (SUNY) at Stony Brook; Louis G. Caston-guay, Department of Psychology, Pennsylvania State University;AdeleM. Hayes, Department of Psychology, University of Miami; David A.Shapiro, PsychologicalTherapies Research Centre, Universityof Leeds,Leeds, United Kingdom.This study was supported in part by Grant MH40196 from the Na-tional Institute of Mental Health. We thank Anne Rees for her untiringefforts in supervising he preparation of the transcriptions of the therapysessions used in this study; Anna Samoilov and Cecily Osley for theirwork on data analysis; Michael Barkham, Gillian Hardy, Shirley Reyn-olds, and Mike Startup for their participation as therapists; Anne Reesand Leslie Morrison for assessment interviews; and Mary Lou Hughesand Jane Revill for administration of the Sheffield Clinic. We also ac-knowledge the helpful comments from Anna Samoilov on an earlierversion of this article.Correspondence concerning his article should be addressed to MarvinR. Goldfried, Department of Psychology, SUNY at Stony Brook, StonyBrook, New York 11794-2500. Electronic mail may be sent via Internetto mgoldfried@ cmail.sunysb.edu.740

integrated interventions with "p ure form " treatments, "deseg-regation" process research is in order (Wolfe & Goldfried,1988). With a clearer understanding of the change processesassociated with different intervention procedures, steps couldthen be taken to de termine the comparative effectiveness of thoseprocesses that are similar and unique to different orientations.

In the search for common processes or principles of change,it has been suggested (Goldfried, 1980) that such commonal itiesmay be usefully construed as existing at a level of abstractionsomewhere between the specific techniques associated with agiven school of therapy and the more general theoretical explana-tion for the effectiveness of these techniques. The focus of thepresent study is on one such principle ; namely, the use of thera-peutic feedback to enhance patients' awareness.

That cognitive bias and selective inatt ention play a signi ficantrole in perpe tuating psychological disorders is a conclusion thathas been drawn by therapists of different orientations (e.g.,Beck, Rush, Shaw, & Emery, 1979; Klerman, Weissman, Roun-savil le, & Chevron, 1984; Strupp & Binder, 1984; Wexler &Rice, 1974). Indeed, the central importance of attention andawareness in psychological funct ioning in general was high-lighted over a century ago by Wi lliam James (18 90), when henoted, "My experience is what I agree to attend to. Only thoseitems which I notice shape my mi nd- -wi th out selective interestmy 'experience is utter chaos" (p. 402). Within the clinicalcontext, therapists may be viewed as providing feedback tohelp patients redeploy their attention to therapeutically relevantaspects of themselves and others, toward the goal of acquiringa new perspective on self and the world.


2/9

COMPARATIVE ANALYSIS 741A probl em that has plagued theoreticians and researchers who

have been interested in conducting comparative process analysesacross orientations has be en the use of different language sys-te ms- ja rg on -a sso ci at ed with a given school Of thought. Witha theoretically biased language system, it is difficult to ascertainwhether the processes of change are similar or different acrossorientations. In accordance with the recommendations made bythe NIM H's workshop on research i n psychotherapy integration(Wolfe & Goldfried, 1988), we used a process coding systemthat made use of the vernacular, providing a language that iscommon to different therapeutic conditions.

The Coding System of Therapeutic Focus (CSTF; Goldfried,Newman, & Hayes, 1989) was developed to code five foci ofthe therapist's feedback: (a) the components of the clients' func-tioning (e.g., emotions, thoughts, act ions); (b) links, in whichconnections are ma de either intrapersonally (e.g., between cli-ent's thoughts and feelings) or interpersonally (e.g., betweenthe actions of another and the actions of the client); ( c) generalinterventions (e.g., reality testing, information giving) ; (d ) peo-ple involved (e.g., parent, therapist); and (e) the time frame ofthe therapeutic focus (e.g., adult past, future).

The CSTF has been used in a number of different researchcontexts (e.g., Castonguay, Goldfried, Wiser, Raue, & Hayes,1996; Castonguay, Hayes, Goldfried, & DeRubeis, 1995; Gold-samt, Goldfried, Hayes, & Kerr, 1992; Hayes, Castonguay, &Goldfried, 1996; Kerr, Goldfried, Hayes, Castonguay, & Gold-saint, 1992). The study most closely related to the present inves-tigation was a preliminar y comparative analysis by Kerr et al.(1992) of the therapeutic focus in sessions with 14 patients whoreceived eight sessions Of cogni tive-b ehavi oral therapy and 13patients treated with psychod ynamic-i nterper sonal therapy inthe Sheffield I study (Shapiro & Firth, 1987). The cognitive-behavioral intervention (called prescriptive) was based on theassumption that psychopathology is a result of intrapersonalissues (e.g., how thoughts influence emotions, ineffective func-tioning at work) and was concerned with teaching self-controlskills, correcting maladaptive thoughts, and modifying the pa-tient's behavior outside the session. By contrast, the focus ofpsychody namic-in terpers onal therapy (called exploratory),based on the assumption that problematic functioning resultsfrom conflicts between the individual and significant others,emphasized the use of the therapeutic relationship to exploreand revise repeated ways of perceiving and relating to others.Consistent with theory, it was found that the psyc hodyn amic -interpersonal interventions focused more on interpersonal thanintrapersonal links. In contrast to theoretical expectation; how-ever, cogni tive-b ehavi oral sessions showed a similar tendencytoward focusing more on interpersonal than intrapersonal links.No bet ween-group differences were found i n the use of eitheran intrapersonal or interpersonal focus.

In the present study, we extend our previous work with theCSTF by comparing the foci of interventions in cogn itiv e-be -havioral and psych odynamic- interpe rsonal sessions from theSheffield II study (Shapiro et al., 1994). Compleme nting thework of Elkin et al. (1989) on the treatment of depression,Shapiro and his colleagues conducted a large-scale comparativeoutcome study to investigate a number of parameters associatedwith treatment of depression (e.g., severity of depression, effec-tiveness of 8 vs. 16 sessions) . Overall, their findings indicated

that both treatment procedures were equally effective, rega rdless,of depression severity. However, the 8-session in tervent ions werefound to be somewhat less effective than the 16-session condi-tion, at least for clients presenting wi th relatively severedepression.

For purposes of our comparative process analysis, we re-stricted our investigation to only the longer term interventioncondition, collapsi ng across severity of depression. Inasmuch asour earlier studies resulted in findings that were both consistentand contrary to theoretical expectations, we did not generateany specific hypotheses as to which CSTF categories woulddifferentiate the therapeutic orientations. However, given themanualized nature of the intervention, we anticipated that, inbeing theoretically consistent, psychodynamic-i nterper sonal n-terventions would focus more on exploration and understanding,whereas cognitive-behavioral interventions would place agreater emphasis on helping clients to cope with difficult lifesituations (Messer, 1986). The goal of this study was to uncovermore specifically how these two orientations are different andsimilar in their more particular therapeutic foci.

Rather than randomly selecting sessions for investigation, wefollowed Greenberg's (1986) suggestion that process researchdeal with particularly effective sessions. According toGreenberg, even though process research need not deal withthe prediction of ultimate outcome, the effective ingredientsassociated with the process of change are more likely to berevealed if one samples therapeutically relevant sessions. Thus,in addition to comparing the therapeutic loci in these two ap-proaches with the treatment of depression, another goa l of thestudy was to compare high- and low-impact sessions withineach orientation.

MethodAs noted, the therapy sessions used in the present investigation werefrom Shapiro et al.'s (1994) study, which involved the random assign-ment of 60 depressed clients to a cognitive-behavioral treatment and60 to psychodynamic-interpersonal reatment. Within each orientation,half of the clients were seen in 8 weekly sessions, and the remainingreceived 16 weekly sessions. The present analyses were based on onlythe 16-session conditions. Clients who were assigned to each therapyorientation were stratified according to high, medium, and low levels ofdepression, as defined by the Beck Depression Inventory (BDI; Beck,Ward, Mendelson, Mock, & Erbaugh, 1961 . Further details regardingthe nature of the design can be found in Shapiro et al. (1994).

ClientsAlthough he original intentionwas to include sessions from 30 clientsfrom each of the two therapy orientations, sessions for 3 clients in thepsychodynamic-interpersonal condition could not be analyzed becauseof either the inability to select high- and low-impact sessions or theunavailabilityof the audiotape for the designated session. Consequently,the final N consisted of sessions from 30 and 27 clients in the cognitive-behavioral and psychodynamic-interpersonal conditions, respectively.All 57 clients included in the current study were diagnosed with majordepressive disorder. The sample consisted of managerial, professional,and white-collar workers whose problems were adversely effecting theiroccupational functioning. Potential clients were initially screened on thebasis of having BDI scores of 16 or above, and whose scores remainedat that level followingan intake assessment.Additionalcriteria for exclu-


3/9

74 2 GOLD FRIED , CASTONGUAY, HAYES, DROZD, AND SHAP IROsion involved the presence of a psychiatr ic d isorder for more than twoyears , having received any form of psychosocia l t reatment during theprevious f ive years , and any change in psychotropic medication duringthe previous 6-week period.

Diagnoses of major depressive d isorder were based on the PresentSta te Examination (PSE; Wing, Cooper, & Sartorius , 1974), and re le-vant i tems from the Diagnostic In terview Schedule (DIS; E aton & Kes-sler, 1985). To be included in the study, clients had to have demon strate da PSE Index of Defin it ion of f ive or more during the 1-month periodbefore the in terview and to have met cr i ter ia for major depressive episodein accordance with the Diagnostic and Statistical Manual of MentalDisorders (3rded.; DSM-II1;Amer ican Psychiatr ic Associa t ion , 1987)within the prior 3 months. Of the 57 clients included in this study, 19%received a d iagnosis of major depression a lone, and the remaining 81%had addit ional d iagnoses of panic d isorder , generalized anxiety d isorder ,or both . All c lients were Caucasian . In the cognit ive-behavi oral condi-t ion , 16 c lients were female , and 14 were male. In the psycho dynam ic-interpersonal therapy, 15 clients were female, and 12 were male. Themean age in the cognit ive- behavioral and psychodynam ic-in terper sonaltherapies was 41 and 42, respectively. Clients in the two therapy condi-t ions d id not d iffer on the basis of any of these pretreatment variables .Further deta ils regarding the se lection procedure and more precise natureof the sample can be found in Shapiro e t a l . (1994).

TherapistsA total of five therapists (3 male, 2 female) conducted both the

cognit ive-behavioral and psychodynamic-in terpersonal treatments . Alltherapists were c l in ical psychologis ts from the United Kingdo m specif i-cally tra ined in each of the two therapy orienta t ions and completed .a tleast four tra in ing cases in each orienta t ion before conducting therapywith c lients in the present s tudy. A noteworthy feature of th is design isthat inasmuch as therapists were trained to deliver both treatments, thepotentia l confounding between personal character is t ics of therapis t andtreatment procedure was ru led out . Each therapis t saw 6 c lients in cogni-t ive-behav ioral therapy and 6 in psychodynamic -in terperso nal therapyin the 16-session condition.Therapy Procedures

Both the cognit ive-behavioral and psychodynamic-in terpersonaltherapies were manual-based (Fir th & Shapiro , 1985; Shapiro & Fir th ,1985). The cognit ive-behavioral in tervention involved a combinationof cognit ive and behavior therapy and made use of procedures suchas anxiety management, tes t ing and correction of maladaptive beliefs ,assert iveness tra in ing, t ime management, and various o ther cognit ive-behavioral procedures . The psycho dynamic -in terper sonal therapy usedboth in terpersonal and experientia l methods and focused primarily onthe use o f the therapeutic re la t ionship and transference as a means fordealing with depression-re la ted in terpersonal re la t ionships. Adherenceratings revealed that therapis ts fo llowed the procedures outl ined in therespective treatments (Star tup & Shapiro , 1993). Further deta ils regard-ing the in tervention procedures may be found in Shapiro e t a l . 1994).

Therapy SessionsWithin the course o f therapy for each client, two therapy sessions were

selected: one having the highest impact, and one having the lowest impact.In selecting the high- and low-impact sessions, we excluded the first andlast three sessions to avoid a ~ ap y focus directed toward initial evaluationand relationship formation and termination issues. The impact of the ses-sion was based on therapists' postsession ratings of helpfulness (Elliott,Barker, Caskey, & Pistrang , 1982), w here 7 = gr eatly helpfu l and 1 =greatly hindering. Client ratings of helpfulness, although obtained after

each session, were insufficiently variable for purposes of discrimination;most sessions were typically rated as helpful by clients.

For sessions to be se lected as having a h igh versus a low impactwith in a course o f therapy, there needed to be a t least a 2-point d ifferencebetween therapis ts ' ra t ings after the session. We summed the therapis tra t ings from three re levant i tems on the Session Evaluation Question-naire (SEQ; Sti les , 1980) and used them to decide on the h igh-lowimpact d ifferentia l in those instances where there was only a 1-pointdifference in therapis ts ' ra t ings of helpfulness . The three 7-point SEQscales were Valuable-Worthless, Special-Ordinary, and Full-Empty. Cli-ent ra t ings were taken in to consideration only when c lients ' ra t ing ofhigh and low helpfulness d irectly reversed those of the therapis t. In suchinstances, an a l ternate h igh or low therapis t-ra ted impact sessio n w asselected to avoid contradic t ion of the c l ient ra t ing .

Coding o f SessionsThe CSTF (Goldfr ied , Newman, & Hayes, 1989) was used to code

transcrip tions of therapis ts ' " tu rns " ( i .e ., therapis ts ' s ta tements afterone c lient u t terance and preceding the next) . The c lients ' s ta tementswere used for contextual information but were not scored. Each codingcategory was scored once per turn as being present or absent. As indi-cated earlier, the CSTF is divided into separate sections: therapist focuson (a) Components of the c l ient 's functioning, (b) In trapersonal andInterpersonal Links, (c) General In terventions, (d) Persons Involved,and (e) Time Frame. Table 1 presents a descrip tion of the coding catego-ries included with in each of these sections.

Each section of the CSTF was coded by a d is t inct group of coders ,with the exception of the Persons Involved and Time Frames, whichwere coded by the same team. Coder teams received between 60 and90 hr of tra in ing by Louis G. C astonguay or Adele M. Hayes, dependingon the section of the code involved. Components , In trapersonal andInterpersonal Links, and General In terventions were scored by advancedgraduate-level students in clinical psychology. Because clinical experi-ence is not required to code the fa ir ly explic i t and s tra ightforward i temsincluded in the Persons Involved and Time Frame sections, advancedpsychology undergraduate-level s tudents and beginning graduate-levels tudents in c l in ical psychology scored these sections. Each transcrip twas coded by two coders , drawn from the pool of f ive to s ix coders thatconsti tu ted each separate team. E ach coder, in their own respective team,coded approximately the same numbers of transcrip ts . Every coder waspaired approximately the same number of t imes with every o ther coder,and the score for each therapy session was based on the average fre-quency of occurrence for the tw o coders . Weekly or b iweekly meetingswere held in a l l coding teams to prevent ra ter dr if t and provide correctivefeedback when necessary .

We calcula ted in terra ter agreements using the formula of in traclasscorre la t ion recommended by Shrout and Fle iss (1979) when each tran-scrip t is coded by a d ifferent se t of coders randomly selected from alarger pool of code rs (i.e., Case 1 ). Th e rater reliability coefficient s forall CSTF items included in the analyses are presented in Table 1. Ascan be see n from Table 1, the reliability was g ood for virtually all codingcategorie s, reaching .60 or above. Given the theoretically relevant natureof certa in coding categories and the somewhat exploratory nature ofthis study, three categor ies with marginal reliabilities (situation = .59,d ifference-incongruity = .59 , and t ime l inks = .54) were included inthe analyses.

R e s u l t sI n a s m u c h a s o u r i n t e r e s t w a s i n c o m p a r i n g t h e r e l a t i v e t h e r a -

p e u t i c f o c u s w i t h i n a s e s s i o n , t h e a v e r a g e f r e q u e n c i e s o f t h et w o c o d e r s f o r e a c h c o d i n g c a t e g o r y w e r e t r a n s f o r m e d i n t op e r c e n t a g e s , r e f l e c t i n g t h e p r o p o r t i o n o f t u r n s w i t h i n a s e s s i o n


4/9

COMPARATIVE ANALYSIS

Tab le 1Descriptions and Coder Reliability or Categories in the Coding System of Therapeutic Focus (CSTF)

7 4 3

Code category Description Intraclass correlations

SituationSelf-observationSelf-evaluationExpectationGeneral thoughtIntentionEmotionActionUnspecified

ComponentsCircumstances external to the patient/client that are relevant to understanding his

or her functioningThought reflecting patient's/client's objective perception of selfPatient's/client's appraisal, judgment, estimation, of own worth or abilitiesThought reflecting patient's/client's anticipation about the futurePatient's/client's thinking that is unspecifiedPatient's/client's future-oriented volition, such as wish, desire, motivation, or needPatient's/client's feelingsPatient's/client's performance of specific behaviorsPatient's/client's functioning where no specific component has been identified

.59

.64.68.73.80.82.95.71.67

Similarity/patternDifference/incongruityConsequence

Intrapersonal LinksSimilarities or recurrences within the patient's/client's functioningDivergences noted within the patient's/client's functioningTherapist implies that a particular component or functioning is having an impacton another component

.80.59.83

PatternCompare/contrastConsequence (self affecting other)Consequence (other affecting self)General interaction

Interpersonal LinksTherapist highlights patient's/client's interpersonal functioning repeated over time,settings, or peopleTherapist compares or contrasts the patient's/client's functioning with that ofanother personPatient's/client's functioning has an impact on another personAnother person's functioning has an impact on patient/clientAn interchange between the patient/client and another that cannot be otherwisecategorized

.62

.73

.65.73.78

Choice/decisionsReality/unrealityExpected/imagined reaction of

otherTherapist supportChangesInformation givingBetween-session experiencesAvoidances

General InterventionsPointing to patient's/client's options, choices, or decisionsHelping patient/client to step out of his or her subjective perception and viewthings more objectivelyPatient's/client's subjective view of another person as it pertains to his or her

interpersonal relationshipTherapist gives reassurance regarding eith er specific or general aspects ofpatient's/client's functioningTherapist refers to patient's/client's change associated with treatmentProviding general facts and knowledge that have therapeutic implications for thepatient/clientTherapist encourages patient/client to act, think, or feel betw een sessionsTherapist points to patie nt's/clien t's thoughts, feelings, or actions that interferewith progress

.65.69

.66

.64

.68.82

.88.76

Patient/clientTherapistParentMateAcquaintance/strangers/others ingeneralPerson links

Persons InvolvedFocus is on the patient or clientFocus is on therapistFocus on patient's/client's parentFocus on patient's/client's current intimate relationshipPerson involved in patient's/client's life that is not captured by any of the otherperson categoriesTherapist makes connection between functioning of people in patient's/client'slife

.9 6.98.98.9 4.96

.60

Preadult pastAdult pastCurrentIn sessionFutureGeneralIrrelevantTime links

Time FrameInfancy through high schoolFrom high school to beginn ingo f therapySince start of therapyWithin present sessionAfter present sessionSpanning more than one time frameTime frame unspecified or irrelevantTherapist notes similarity or difference between different times in patient's/client's life

.98.86.70.87.81.66.98.54


5/9

744 GOLDFRIED, CASTONGUAY, HAYES, DROZD, AND SHAPIROin which the therapist focused on a given CSTF category. Wecalculated percentages by dividing the frequen cies of each cate-gory by the number of turns in each session. Table 2 presentsthe means and standard deviations on each code category for thecogni t ive-behavioral and psychodynamic-interpersonalgroupsas a whole, as well as for the high- and low-impact sessions.

Given that the distributions for perc enta ge scores are typicallyskewed, the scores for each code category were normalized bymeans of arcsin transformations before statistical analyses. Asour interest was in the differential use of categories in each of

the separate sections of the CSTF within cognitive-beha vioraland psychody namic-i nterper sonal high- and low-impact ses-sions, we conducted 2 x 2 analyses of variance (ANO VA s) -crossing therapeutic orientation with session impact on eachcode category within the five separate sections of the code:Components, Intrapersonal and Interpersonal Links, General In-terventions, Pers ons Inv olved, and Time Frame. Differenceswere considered to be statistically significant if the probabilitylevel was equal to or less than .05.

The results for the ANOVAs computed on the therapeuticTable 2Mean Percentages (and Standard Deviations) of Therapist Turns for Each CSTF Category inCognitive-Behavioral and Psychodynamic-Interpersonal Sessions

Cognitive-b ehavioral (n = 30) Psychodynamic -interpersona l (n = 27)Total High impact Low impact Total High impact Low impact

Section and category M SD M SD M SD M SD M SD M SDComponentsSituation 8.3 3.5 8.4 5.4 8.3 4.3 6.7 4.2 5.4 5.5 7.9 5.5Self-observa tion 2.1 1.7 2.5 3.0 1.8 1.3 2.1 1.6 2.1 2.1 2.1 1.9Self-evaluation 3.4 2.9 3.7 4.1 3.1 2.7 5.5 3.8 6.1 5.6 4.8 4.2Expectat ion 9.9 4.4 10.0 5.7 9.8 4.8 10.7 6.1 9.7 6.9 11.8 6.3General thought 20.6 6.4 21.4 7.6 19.8 7.4 24.1 10.1 23.2 10.8 24.9 10.7Intention 10.5 4.8 9.8 5.6 11.3 6.2 12.6 5.9 12.3 7.3 12.9 6.2Emot ion 11.8 5.6 12.5 6.9 11.1 6.3 25.6 10.6 27.5 11.8 23.7 11.3Action 27.4 9.5 26.7 10.6 28.1 10.2 25.0 7.9 25.1 10.4 24.9 8.0Unspecified 39.7 8.0 38.9 10.3 40.3 7.9 44.1 9.8 44.0 11.6 44.1 9.9Intrapersonal LinksSimilarity/pattern 5.4 2.5 5.6 4.3 5.2 2.8 7.1 4.1 7.4 5.6 6.9 3.7Difference/incongruity 3.0 1.4 2.9 2.0 3.0 2.4 5.9 3.2 6.1 4.5 5.6 3.2Consequence 13.2 6.0 13.3 6.8 13.2 6.9 15.7 9.1 16.9 11.5 14.4 8.2Interpersonal LinksPattern 2.2 1.7 2.2 2.4 2.3 2.2 4.7 3.1 5.2 3.9 4.3 3.5

Compare/contrast 1.8 1.5 1.6 1.4 2.1 2.0 3.0 2.7 3.2 3.5 2.8 2.8Consequence (self affecting other) 2.9 2.3 2.4 1.8 3.5 3.6 4.2 2.7 4.4 3.4 4.1 3.2Consequence (other affecting self) 5.1 3.5 4.5 3.6 5.7 5.2 8.2 4.2 8.9 5.8 7.5 4.6General interaction 4.6 2.3 4.9 3.7 4.2 2.7 7.9 5.2 9.0 7.1 6.7 4.1General InterventionsChoice/deci sions 3.1 2.8 3.2 3.6 2.9 3.5 1.4 1.7 1.7 2.9 1.1 1.3Reality/unreality 3.7 2.6 3.0 2.7 4.4 4.9 4.3 3.6 3.4 3.4 5.2 5.5Expected/imagined reaction ofother 1.5 1.2 1.5 1.5 1.5 1.9 5.7 4.4 5.3 4.9 6.2 5.5Therapist support 2.2 1.8 2.9 3.7 1.4 1.1 1.0 1.0 1.2 1.3 0.8 1.2Changes 2.9 3.2 4.1 6.0 1.8 1.5 2.6 2.3 2.7 2.6 2.5 3.4Information giving 2.4 1.9 2.7 2.5 2.1 2.3 1.4 1.8 1.7 2.2 1.0 2.1Between-session experiences 7.0 5.9 6.3 8.9 7.6 6.3 0.6 0.9 0.5 1.0 .01 1.6Avoidances 1.9 2.2 1.9 3.9 1.8 2.2 5.7 4.9 5.7 4.8 5.7 7.2Persons InvolvedPatient/client 68.5 11.0 69.7 11.3 67.2 17.4 72.1 19.0 69.5 28.9 74.8 15.0Therapist 2.2 3.2 2.4 2.8 2.0 4.8 8.0 7.9 9.2 11.0 6.7 8.9Parent 2.2 5.5 2.2 4.3 2.2 7.5 8.4 7.0 10.9 12.9 5.9 8.1Mate 4.5 4.1 4.1 4.7 5.0 5.4 5.9 6.2 6.4 7.4 5.5 6.5Acquaintance/strangers/others 18.4 9.1 19.9 10.5 17.0 12.7 19.1 7.5 19.9 9.4 19.1 10.6Person links 0.7 0,6 0.8 0.9 0.6 0.8 2.2 2.0 2.3 2.2 2.2 2.5Time FramePreadult past 1.1 3.1 1.8 5.5 0.3 0.9 10.2 12.4 15.7 27.6 4.8 11.8Adult past 4.4 5.3 5.5 9.0 3.2 4.8 7.3 6.2 7.4 7.0 7.2 9.2Current 42.3 10.2 42.1 13.4 42.5 14.0 45.2 16.2 40.5 23.2 49.8 16.7In sess ion 4.3 3.8 5.6 6.6 2.9 3.2 7.5 4.3 8.0 6.5 6.9 5.1Future 31.5 8.9 29.6 10.1 33.5 12.1 17.9 10.6 16.1 14.7 19.6 10.5General 17.0 6.1 18.2 7.7 15.8 9.3 26.6 10.2 26.4 15.6 26.8 10.4Irrelevant 25.5 11.1 25.9 11.1 25.0 12.9 18.8 12.3 17.4 13.4 20.2 12.6Time links 1.4 1.2 1.8 2.0 1.0 1.1 2.7 2.1 3.4 3.4 2.0 1.4

Note. CSTF = Coding System of Therapeutic Focus.


6/9

COMPARATIVE ANALYSIS 74 5

focus codes for all five sections of the CSTF are summarizedin Table 3. Of the nine analyses carried out for specific compo-nents of the client 's functioning, statistically significant maineffects for treatment orientations were found for only two com-ponents: emot ion and s i tua t ion . Psychodynamic- in te rpersona l

in te rvent ions p laced twice as much emphasis on emot ion ascogni t ive-behaviora l in te rvent ions. Converse ly , cogni t ive-be-havioral se ssions were mor e likely to focus on the externalsituational circumstances in the client 's l ife . No significant dif-ferences were obtained for session impact or for interactionsbetween orientation and impact.

With r egard to the ANOVAs condu cted on Intr.apersonaI andInterpersonal Links, five of the eight comparisons revealed sig-nificant main effects between therapy orientations. Specifically,psychody namic- i n te rper sona l sessions placed more of a the ra-peutic focus on similarit ies and patterns within clients' function-ing, as well as differences or incongruities that may exist be-tween aspects of their functioning. At the level of interpersonall inks made , ps ychodynami c- in te rperso na l in te rvent ions a lsowere more likely to highlight interpersonal patterns, focus onthe impact that others made on clients, and deal in general withtheir interpersonal relations. No significant differences were

Table 3Analysis of Variance of Therapy Orientation and Session Impact for the Coding System ofTherapeutic FocusMain effects Main effects Orientationof orientation of impact Impact

Section and category F p F p F pComponentsSituation 4.28 .05 < 1 - - < 1 --Self-observation < 1 -- < 1 -- < 1 --

Self-evaluation 2.25 .14 < I - - < 1 --Expectation


7/9

746 GOLDFRIED, CASTONGUAY, HAYES, DROZD, AND SHAPIROfound between orientations with regard to highlighting howclients' functioninghas consequences for another or the compar-ison between clients' func tioning and that of someone else. Nosignificant differences were found for session impact or for theinteraction between orientation and impact.

Of the eight categories within the General Interventions sec-tion of the code, six were found to differentiate significantlybetween the two therapy orientations. In comparison with cogni-tive-behavioral interventions, psychodynamic-interpersonalsessions were more likely to highlight clients' subjective inter-pretation of another person's functioning and to note how clientsmight be behav ing in such a way as to interfere with the processof therapy. By contrast, cognitive-behavioral sessions weremore likely to refer to possible choices or decisions that clientsmight make in their life, to offer them support and reassurance,to provide them with therapeutically relevant information, andto encourage them to engage in between-session experiences.

No main effects were found between the therapy orientationswith regard to the tendency to provide a more realistic contrastto clients' unrealistic view of things or to note any therapeuticchanges that might have been made. A main effect was foundfor impact, whereby high-impact sessions were more likely toinclude the therapist's support and information than were low-impact sessions. No significant interactions were found betweenorientation and impact.

The findings that deal with the therapist's focus on differentPersons Involved in the client's life revealed that three of thesix comparisons had significant main effects between therapyorientations. Compared with cognitive-behavioral sessions,psychodyn amic-interp ersonal nterventions were more likely toplace a focus on the therapist and on the client's parent and weremore likely to draw parallels or similarities between differentindividuals in the cl ient 's life. There were no significant differ-ences with regard to the therapist's focus on clients, their part-ners, or other people in general. A significant main effect wasfound for session impact, whereby low-impact sessions wereless likely to involve a focus on the client. There were no sig-nificant interactions between orientation and impact.

For Time Frame, six of the eight comparisons resulted in signifi-cant main effects between orientations. ANOVAs revealed that psy-chodynamic-interpersonal nterventions were more likely to focuson preadult past, adult past, what was occurring within session,and events that generally tended to cover more than one time frame;they were also more likely to make specific l inks between clients'functioning at one point in life and their functioning at anotherpoint. In contrast to psychodynamic-interpersonalsessions, cogni-tive-behavioral interventions were more likely to focus on futureevents and to highlight material in which the time frame wasirrelevant or unimportant. The analyses also revealed significantmain effects for therapy impact, in that there was a greater likeli-hood to focus on what was occurring within the session and tomake links between time periods in high-impact sessions, regard-less of therapy orientation. No difference between orientations wasfound for current time frame, and no interactions were obtainedbetween orientation and session impact.

DiscussionUsing the CSTF as a common metric for a process analysis

of cognitive -behavior al therapy and psychodynamic- interper -

sonal therapy, we found that a number of findings emerged.Psychodyna mic-interper sonal nterventions were found to focusmore on emotion, intrapersonal patterns, and discrepancies-incongruities within clients' functioning. They were also morelikely to highlight interpersonal patterns in clients' lives, theimpact that others made on them, their expec tation of how otherswould react to them, their genera l interpersonal interactions, andwhat they were doing that interfered with the process of therapy.Finally, therapists in the psychodyn amic-interp ersonal condi-tion placed more of an emphasis on themselves and clients'parents; a time frame that dealt with clients' childhood, adultpast, events within the session itself, what occurred across dif-ferent periods in the client's life, as well as parallels amongpeople in the c lient's life and continuities or discontinuities overtime. By contrast, c ognitive- behavior al sessions placed moreemphasis on external circumstances in clients' lives and theirability to choose and make decisions, and they offered moresupport, information, and the encouragement to engage in be-tween-session experiences. They also focused more on futureevents and provided interventions in which no particular timeframe was relevant.In the most general sense, psychodyna mic-interp ersonal her-apy underscored the importance of "insight," whereas cogni-tive-b ehavior al therapy emphasized the importance of " act ion"(Messer, 1986; Wachtel, 1987). The therapeutic focus withinpsychodYnamic-interpersonal sessions was on w h a t h a s n o twork ed in the pas t . These interventions attempted to provideclients with a better understand ing about the nature of theirdifficulties, particularly those of an interpersonal nature. Theeffect that others have on clients and the particular ways theymay misperceive or distort things about others was presentedas being part of a larger theme in their life. Where this patterncomes from, and how it manifests itself within the session andacross the lifetime of clients, especially in their relationshipwith parents, was salient. All this occurred within an emotionalcontext, in which therapists pointed out to clients some of thedifficulties that they may have with these issues.

By contrast, co gnitive-b ehavioral interventions focused onwhat clients could do to deal more e f fec t ive ly wi th events inthe fu ture , particularly how they may cope with problematic,external, environment al circumstances. To help clients betterdeal with such circumstances, cognitive-behavioral sessions,made use of a psychoeducational approach, imparting knowl-edge that might enhance clients' ability to cope. The focus wasmore on the future, particularly what may be done betweensessions to facilitate competent functioning. These findings areconsistent with our past process analyses and those of othersthat have found an exploratory and interpersonal emphasis inpsychodynamic sessions, compared with the more prescriptivefocus in cognitive-behavioral interventions (Goldsamt et al.,1992; Kerr et al., 1992; Stiles, Shapiro, & Firth-Cozens, 1989).

Another finding in the present study was the tendency forpsychodyn amic-interp ersonal interventions to be "richer," inthe sense that more categories were used within each therapysession than in c ognitive- behaviora l sessions. In contrast to 7coding categories on which there was a significantly greaterfocus within cogn itive-b ehavior therapy, there were 16 catego-ries on which psychodyna mic-interper sonal therapy placed agreater focus. Although this may reflect the possibility that psy-


8/9

COMPARATIVE ANALYSIS 747chodyna mic-in terper sonal therapy went beyond symptom re-duction, the two therapies did not differ in enhancing socialfunctioning and self-esteem (Shapiro et al., 1994). Thus, itcannot be co ncluded that an intervention with a broader focusis necessarily a therapeutically more effective one.

There were certain aspects of the therapeutic focus in whichthe two orientations did not differ. Whereas certain sections ofthe code resulted in several differences (e.g., Time Frame),others (e.g., Components) revealed few differences. There wasa comparable focus on self-observation (i.e., encouraging clientsto be more objective observers of themselves), self-evaluation,expectations, thoughts in general, intentions, and actions. AnIntrapersonal Link that failed to differentiate the two therapiesoccurred when the therapist highlighted how one aspect of theclient 's functioning was the cause of another (e.g., thoughtsinfluencingemotions, emotions influencingaction). With regardto Interpersonal Links, no difference was found in therapists'comparison of client s' function ing with that of others, or incompar ing the impact that clients were having on others. GeneralInterventions that did not differentiate the two orientations weretherapists' attempts to help clients update their perception ofevents in light of reality and to note changes that had beenoccurring in clients. They were also similar in the amou nt thatthey focused on clients and their partners and in their emphasison what was occurring in clients' current life situation.

It is possible that some differences failed to emerge as a resultof insufficient statistical power, a methodological constrai nt noteasily overcome in the process analysis of archival data. Inaddition, we cannot conclude that the content and function ofthe therapeutic focus are comparable, even if there is compara-bility in the coding category. Thus, it is possible that, althoughboth orientations focused on clients' actions in approximately25% of the turns, the content of the behavior may have differed(e.g., psychody namic-in terperso nal sessions focusing more oninterpersonal behavior ). Moreover, the function of an interven-tion may differ even if the frequency of its use does not. Forexample, findings from an earlier study revealed that the func-tion of correcting clients' perceptions in light of reality wasdifferent in these two orientations. Whereas cognitive-behav-ioral interventions were conveying the message "things are notas bad as you think," p sychodyna mic-int erperson al interven-tions were attempting to have clients recognize that "things arenot as good as you think" (Castonguay et al., 1990). Still, thepossibility that the findings of the present study reflect points ofconvergence between the two orientations cannot be dismissed.

A second goal of the study was to explore whether therewould be differences in therapeutic focus between high- andlow-impact sessions. In contrast to 59% of the differences be-tween orientations that were statistically significant, only 10% ofthe differences were found to be significant for session impact,slightly above what one may expect to find by chance. In addi-tion, there were no significant interactions between therapy ori-entations and session impact. The fact that the therapy wasmanual-based and implemented by therapists experienced withthe procedures may have resulted in greater consistency fromsession to session. On the basis of an informal content analysis,the high-impact sessions appeared to be those in which thetherapist worked within the orientation's framework and inwhich the cli ent responded accordingly. In low-impact sessions,

the therapist attempted to work with in the therapeutic mode, butclients were unable to do so because of resistance or noncompl i-ance because they attempted to pursue the other intervention(e.g., a cogni tive- behavi oral client who wanted to focus on thepast), or because the focus was on realistic life events that didnot readily lend themselves to either exploration or coping (e.g.,losing a job).In interpreting these findings, one must keep in mind that thesewere manual-driven interventions implemented in a controlledoutcome study, and it is an open question whether differentresults would be obtained in the study of nonmanualiz ed inter-ventions within a naturalistic setting. Given the fact that anincreasing number of clinicians have reported that they use pro-cedures from other orientations because they find it more clini-cally helpful (Norcross & Goldfried, 1992; Stricker & Gold,1993), it is possible that fewer differences would be foundbetween the two orientations. In the final analysis, whether atherapy as practiced is "pure" or "integrated," the questionof effectiveness needs to be determined independently, in therelationship of these interventions to ultimate outcome.

ReferencesAmerican Psychiatric Association. (1987). Diagnostic and statistical

manual of mental disorders (3rd ed.). Washington,DC: Author.Arnkoff, D. B., & Glass, C. R. (1992). Cognitive therapy and psycho-therapy integration. In D. K. Freedheim (Ed.), History of psychother-apy: A century o f change (pp. 657-694). Washington,DC: AmericanPsychological Association.Beck, A. T., Rush, A. J., Shaw, B. E, & Emery, G. (1979). Cognitivetherapy o f depression. New York: Guilford Press.Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J.( 1961 ). An inventory for measuring depression.Archives o f GeneralPsychiatry, 4, 561-571.Castonguay, L. G., & Goldfried, M. R. (1994). Psychotherapy integra-tion: An idea whose time has come. Applied and Preventive Psychol-ogy, 3, 159-172.Castonguay, L. G., Goldfried, M. R., Hayes, A. M~, Raue, P.J., Wiser,S.L., & Shapiro, D. A. (1990, June). Quantitative and qualitativeanalyses of process-outcome data fo r different therapeutic ap-proaches. Presented at the 21st meeting of the Society for Psychother-apy Research, Wintergreen, VA.Castonguay, L. G., Goldfried, M. R., Wiser, S. L., Raue, P. J., & Hayes,A. M. (1996). Predicting the effect of cognitive therapy for depres-sion: A study of unique and common factors. Journal of Consultingand Clinical Psychology, 64, 497-504.Castonguay, L. G., Hayes, A. M., Goldfried, M. R., & DeRubeis, R. J.(1995). The focus of therapist interventions in cognitive therapy fordepression. Cognitive Therapy and Research, 19, 485-503.Eaton, W.W., & Kessler, L.G. (Eds.). (1985). Epidemiologic fieldmethods in psychiatry: The NIMH Epidemioligic Catchment AreaProgram. San Diego, CA: Academic Press.Elkin, I., Shea, M.T., Watkins, J.T., Imber, S.D., & Sotsky, S.M.,Collins, J. E, Glass, D.R., Pilkonis, P.A., Leber, W. R., Docherty,J.P., Fiester, S.J., & Parloff, M.B. (1989). National Institute ofMental Health Treatment of Depression Collaborative Research Pro-gram: General effectiveness of treatment.Archives o f General Psychi-atry, 46, 971-982.Elliott, R., Barker, C. B., Caskey, N., & Pistrang, N. (1982). Differentialhelpfulness of counselor verbal response modes. Journal o f Counsel-ing Psychology, 29, 354-361.Firth, J., & Shapiro, D. A. (1985). Prescriptive therapy m anual fo r the


9/9

748 GOLD FRIED, CASTONGUAY, HAYES, DROZD, AND SHAPIR OSheffield P sychotherapy Project ( SAP U Memo No. 734). Sheffield,England: Medical Research Council/Economic and Social ResearchCounc il, Social and Applie d Psychology Unit, University of Sheffield.

Goldfried, M. R. (1980). Toward the delineation of therapeutic changeprinciples. American Psychologist, 35, 991-999.

Goldfried, M. R. (1991). Research issues in psychotherapy integration.Journal o f Psychotherapy Integration , 1, 5 - 2 5 .

Goldfried, M. R., Newman, C. E, & Hayes, A. M. (1989). The codingsystem o f therapeutic focus. Unpublished manuscript, State Universityof New York at Stony Brook.

Goldsamt, L. A., Gold fried, M. R., Hayes, A. M., & Kerr, S. (1992 ).Beck, Meichenbaum, and Strupp: A com parison of three therapies onthe dimension of therapeutic feedback. Psychotherapy Research, 29,167-176.

Greenberg, L.S. (1986). Change process research. Journal of Con-sulting and Clinical Psychology, 54, 4 - 9 .

Hayes, A. M., Castonguay, L. G., & Goldfried, M. R. (1996). The effec-tiveness o f targeting the vulnerability factors of depression in cognitivetherapy. Journal of Consulting and Clinical Psychology, 64, 6 2 3 -627.

James, W. (1890). The principles of psychology. New York: Holt.Kerr, S., Gold fried, M. R., Hayes, A. M., Castonguay, L. G., & Gold-

samt, L. A. (199 2). Interpersonal and intrapersonal focus in cogni-tive-behavioral and psychodynamic-interpersonal therapies: A pre-liminary analysis of the Sheffield Project. Psychotherapy Research,2, 266-276.

Klerman, G.L., Weissman, M.M., Rounsaville, B., & Chevron, E.(1984). Interpersonal psychotherapy of depression. New York: BasicBooks.

Messer, S.B. (1986). Behavioral and psychoanalytic perspectives attherapeutic choice points. American Psychologist, 41, 1261-1272.

Norcross, J. C., & Goldfried, M. R. (Eds.). (199 2). Handbook o f psy-chotherapy integration. New York: Basic Books.

Shapiro, D. A., Barkham, M., Ree s, A., Hardy, G. E., Reynolds, S., &Startu p, M. (1 994 ). Effects of treatment duration and severity o fdepression on the effectiveness of cognit ive -beh avio ral and psycho-

dynamic-interpersonal psychotherapy. Journal of Consulting andClinical Psychology, 62, 522-534.Shapiro, D. A., & Firth, J. (1985). Exploratory therapy Manual fo r theSheffield Psychotherapy Project (SAPU Memo No. 733). Sheffield,United Kingdom: Medical Research Council/Economic and SocialResearch Council, Social and Applied Psychology Unit, University ofSheffield.Shapiro, D. A., & Firth, J. (1987 ). Prescriptive v. explora tory psycho-therapy: Outcom e of the Sheffield Psychotherapy Project. British Jour-nal of Psychiatry, 151, 790-799.Shrout, P.E., & Fleiss, J. L. (197 9). Intraclass correlations: Use in

assessing rater reliability. Psychological Bulletin, 86, 420-428.Startup, M. J., & Shapiro, D. A. (1993). Therapist treatment fidelity inprescriptive vs. explorato ry psychotherapy. British Journal of ClinicalPsychology, 32, 443-456.Stiles, W. B. (19 80). Measurement of the impact of psychotherapy ses-

sions. Journal o f Consulting a nd Clinical Psychology, 48, 176-185.Stiles, W. B., Shapiro, D. A., & Firth-Cozens, J. A. (1 989 ). Therapistdifferences in the use of verbal response mo de forms and intents.Psychotherapy, 26, 314-322.

Stricker, G. (1994). Reflections on psychotherapy integration. ClinicalPsychology: Science and Practice, 1, 3 - 1 2 .Stricker, G., & Gold, J. R. (Eds.). (1993). Comprehensive handbook ofpsychotherapy integration. New York: Plenum.Strupp, H. H., & Binder, J. (1984). Psychotherapy in a new key. Ne wYork: Basic Books.Wachtel, P. L. (1987). Action and insight. New York: Guilford Press.Wexler, D.A., & Rice, L.N. (Eds.). (1974). Innovations in client-centered psychotherapy. New York: Wiley.Wing, J. K., Cooper, J. E., & Sartorius, N. (1 974 ). The measurementand classification of psychiatric symptoms. Cambridge, England:Cambridge University Press.Wolfe, B. E., & Goldf ried, M. R. (19 88). Research o n psychotherapy

integration: Recommendations and conclusion from an NIM H work-shop. Journal of Consulting and Clinical Psychology, 56, 448-451.R e c e i v e d S e p t e m b e r 4 , 1 9 9 6

R e v i s i o n r e c e i v e d D e c e m b e r 1 1, 1 9 9 6Acce pted March 3 , 1997

a comparative analysis of the therapeutic focus in cognitive behavioral and psycho dynamic...

Documents