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Krause y Altimir (2016) Introduction Current Developments in Psychotherapy Process Research
Krause y Altimir (2016) Introduction Current Developments in Psychotherapy Process Research
Studies in Psychology
To cite this article: Mariane Krause & Carolina Altimir (2016) Introduction: current
developments in psychotherapy process research / Introducción: desarrollos actuales en
la investigación del proceso psicoterapéutico, Estudios de Psicología, 37:2-3, 201-225, DOI:
10.1080/02109395.2016.1227574
Abstract: The questions that guide psychotherapy process research are: what
changes in psychotherapy? And, how does that change occur? These ques-
tions have been present in clinical settings and psychotherapy research for
decades, generating a substantial amount of knowledge for the discipline.
Based on a questioning of the limitations of traditional psychotherapy
research, whose primary focus has been the study of final outcomes of
treatment, this area of research has exposed important conceptual and meth-
odological proposals for the study of the process. Despite its long and
productive tradition, research into the psychotherapeutic process is currently
gathering a new momentum from the growing conviction of the need to focus
efforts on studies that can account for the elements, mechanisms and pro-
cesses associated with change. In this introduction we organize the field of
psychotherapy process research, according to its units of analysis — macro-
or micro-processes — and the foci on which they are based: content, factors
and mechanisms of change. The different ways in which these components
are organized are exemplified with the articles included in this monograph.
We then give an overview of the most used methods in this field of study, also
referring to the studies that report on the application of these methods in this
special issue of Studies in Psychology.
Keywords: psychotherapy process research; psychotherapeutic change;
psychotherapy microanalysis
assimilates her fear of dying. Using a primarily qualitative approach, the authors
describe Olivia’s trajectory of change throughout the therapy sessions as a process
they define as ‘fluctuating and irregular’. The focus of this study is the patient’s
change in her problematic experiences that result from her fear of dying and its
progressive assimilation and integration to the self. The study unit is the therapy
as a whole, with special emphasis on the trajectory followed by this process,
including its progress and setbacks. It could be said that one of the benefits of this
study is its attempt to characterize the change trajectory in the context of a
particular therapeutic approach, in this case, Brief Strategic Therapy.
For their part, Águila et al. (2016), exponents of an emerging line of investiga-
tion within the study of the process, place child clinical psychology as an object of
study of the therapeutic process. The authors seek to adapt models of process
research to therapy with child population, whose characteristics differ from the
traditionally studied adult therapy. Through their analysis of the therapists’ narra-
tives, they discuss the applicability of Krause et al.’s (2006, 2007) Generic
Change Indicators model to therapy with children and adolescents who are
victims of sexual abuse. While, like the previous study, this research focuses on
the complete therapy as the unit of analysis, it does so from the therapists’
perspective of their patients’ change. Basing itself on the therapists’ subjective
experience, the study proposes a model for the evolution of change, which
distinguishes three separate stages in which the alliance plays a fundamental
role and is configured in different ways. Thus, the focus of study refers to the
factors associated with change, in this case the alliance, and the contents of that
change, associated with each identified phase: connection with the therapeutic
space, redefinition of the abusive experience and consolidation of changes.
Complementing the above, but from an observer’s perspective, Ramos et al.
(2016) describe the change process in the case of a group psychoanalytic psy-
chotherapy for a six-year-old girl. Using an observational method developed by
the authors, they identify change indicators observed in the patient and the
therapist interventions that facilitate those changes. Their results suggest that the
changes are linked to progress in the process of symbolization and mentalization.
The patients’ perspective regarding the change process is also represented in
this special issue by the authors Schürmann and Mühlmeyer-Mentzel (2016).
Taking the therapy as the unit of analysis, the authors conducted a meta-
analysis with qualitative data from patients’ reports. Based on this they propose
a model that gradually develops clients’ resources during psychotherapy. The
model distinguishes between early stages of change, whose content and mechan-
isms include, first, the activation of behaviour and the beginning of the internal
change process, and second, the subsequent stages, which include self-
actualization, and behavioural changes. Like the authors mentioned above,
Schürmann and Mühlmeyer-Mentzel (2016) report a characterization of the ther-
apeutic process according to stages of its progression.
In a similar vein, the qualitative analysis of interviews with patients conducted
by Abarzúa, Silva, Navarro, and Krause (2016) focuses on the change process in
people diagnosed with schizophrenia, placing this particular population as the
206 M. Krause and C. Altimir
study, and by Krause et al. (2016), where the Therapeutic Activity Coding System
(TACS) was applied to transcripts of significant events, in order to capture
therapists and patients’ verbalizations associated to change.
As can be seen in this traversal look at the data collection methods used by the
studies in this special issue, psychotherapy process research has been prolific to
the point of generating its own methods, whose ultimate goal is to capture the
detail of relevant variables of change within psychotherapy. Some of these
methodologies respond to the conceptual framework of certain psychotherapeutic
schools, such as the method used in the article by Maldavsky (2016), which
studies wishes, defences and their state in patients’ narratives, while others, such
as APES or SCAT, are intended to be generic in the sense of being independent
from different psychotherapeutic schools.
However, process research does not only create new methodologies, but also
applies more conventional procedures to its data collection, combining them with
the previously mentioned innovative alternatives. Among these, the interview (to
patients or therapists) is a widely used method, applied in a standardized format —
the clinical interview — in the study by Montesano and Izu (2016), or in a semi-
structured format in the work by Abarzúa et al. (2016) and by Águila et al. (2016).
These semi-structured interviews — widely used in psychotherapy research — are
the tool of choice because they capture participants’ recollections on the change
process. As demonstrated by Schürmann and Mühlmeyer-Mentzel’s (2016) qua-
litative meta-analysis, by using qualitative data from interviews the progression of
change can be reconstructed — both in its content and mechanisms, as and in
terms of the elements that facilitated that change.
The complexity of the data derived from psychotherapeutic processes —
captured by sophisticated observational systems and coding of verbal and non-
verbal activity — are often also supplemented with information gathered from
self-report instruments, answered by patients or therapists themselves. Such
instruments were included in the designs of most studies in this special issue,
but played a greater role in certain ones, such as in the work by Constantino et al.
(2016). This study, which serves to illustrate how to integrate self-report instru-
ments in study designs of the psychotherapeutic process, assesses the impact that
expectations of post-treatment results have on psychotherapy in depressed
patients. It applies instruments that are widely used around the world to assess
symptoms of depression and anxiety, such as the Beck Depression Inventory
(BDI-II, Beck, Steer, & Brown, 1996), the Beck Anxiety Inventory (BAI; Beck,
Epstein, Brown, & Steer, 1988) and the Patient Health Questionnaire-9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001), along with others — widely used in
therapeutic process research — such as the Working Alliance Inventory (WAI;
Horvath & Greenberg, 1986) and the Therapeutic Factors Inventory (TFI-S;
MacNair-Semands, Ogrodniczuk, & Joyce, 2010). In this study, in addition to
the measures directed towards the symptoms (and their potential decrease),
instruments are applied to capture other changes that are the result of psychother-
apy: Quality of Life Inventory (QOLI; Frisch, Cornell, Villanueva, & Retzlaff,
1992), Inventory of Interpersonal Problems-28 (IIP-28; Pilkonis, Kim, Proietti, &
210 M. Krause and C. Altimir
Barkham, 1996), together with the specific instrument that evaluates the research
study object, the Outcome Expectations Scale (OES; Ogrodniczuk & Sochting,
2010). In psychotherapy process studies, patients usually take questionnaires at
different stages of their psychotherapy, including at the beginning, certain middle
points and on completion. In the case of the Constantino et al. (2016) study,
instruments are applied during the initial phase of therapy, specifically in sessions
1 to 5, and during post-treatment. These different evaluation points facilitate
identifying the relationship the different input variables have with both the initial
evolution of the process and the final results. These types of studies are also
valuable for clinical practice, as their results provide ‘markers’ that can potentially
allow a monitoring of the evolution of the psychotherapeutic process.
The quantitative instruments applied to the study of the psychotherapeutic
process are used in different cultural contexts and therefore require validation for
each. In this special issue we have included two studies whose contribution is
precisely the adaptation of an instrument to a new cultural context. Thus, Díaz-
Oropeza and Peña-Leyva (2016) have provided the psychotherapy research com-
munity with a Spanish version of the Therapeutic Alliance Negotiating Scale, and
Gómez-Penedo, Barrientos, Martínez, and Roussos (2016) have validated the
Spanish version of the Comparative Psychotherapy Process Scale (CPPS).
In terms of research designs, process studies are diverse. However, since in-
depth analysis through the inclusion of a multiplicity of variables, which are
measured at different times during the evolution of psychotherapy and in natural
contexts, is favoured, it is usual for sample sizes to be relatively small, being also
abundant case studies. Following this trend, this special issue includes several
case studies, including one by Ramos et al. (2016), which analyses the change
process in a psychoanalytic group psychotherapy for children; one by Montesano
and Izu (2016), who studied couple therapy; and one by von Mengden-
Campezatto et al. (2016), who analysed the conditions associated with the inter-
ruption of a therapeutic process in a patient with borderline personality disorder.
These case studies present a complex methodological design, which aims to
understand the interrelationship between the different variables that influence
the effect (or no effect) of therapy, combining qualitative and quantitative meth-
ods, and assessments at different times during the process.
Regarding the analysis of data, integrating qualitative and quantitative meth-
ods is common, as is quantifying information — through coding manuals — from
an initial qualitative analysis carried out by observers or judges. When studies
include a set of therapies, they use methods of analysis that consider the quality of
‘nested data’ of the information gathered. This is the case of the study by Krause
et al. (2016), which considered that the primary data ‘speaking turn’ was nested in
episodes of therapy, which in turn belonged to a particular therapy. This analysis,
carried out by Hierarchical Modeling, considers the complex interplay of variables
in these different levels of analysis.
It is important to note that current process studies not only analyse what
happens within the therapy, that is, the progression of change, its mechanisms
and determinants, but — and increasingly frequently — they also consider final
Psychotherapy process research / Investigación del proceso psicoterapéutico 211
results, thus becoming ‘process-outcome studies’. The end result can be included
in the study design as a dependent variable, and can thus relate events from the
process with the final effect or can be considered for classification and subsequent
comparison of therapies. In any case, not being blind to the final results is relevant
to the investigation of the process. However, this inclusion may involve a con-
ceptual challenge, as sometimes the notions of change involved in certain process
evaluations do not coincide with those implicit in the instruments that assess final
results.
Finally, this special issue contains a review of a book that is relevant to current
research in psychotherapy, entitled Psychotherapy Research: Foundations,
Process and Outcome, edited by Gelo, Pritz, and Rieken (2015). The review by
Espinosa (2016) presents the book as a ‘roadmap’ that is essential for any reader
who would like to learn about the field of psychotherapy research or deepen and
update their knowledge. Psychotherapy process research has a leading place in
this book, which includes both its history and current developments.
Our intention when putting together this special issue in psychotherapy pro-
cess studies was to expose the diversity and complexity of different foci and units
of study, methodological approaches and the wealth of its results. We hope,
through these works, to give even more visibility to this area of research,
contribute to the discussion that surrounds it, encourage psychotherapeutic pro-
cess researchers to continue developing studies in this area and encourage clin-
icians to consider their results in their practices.
212 M. Krause and C. Altimir
metodológicas cuyo foco esencial es esclarecer los procesos que tienen lugar al
interior de la terapia y que se relacionan con el cambio. En su momento, este
movimiento cuestionó las limitaciones que enfrentaba la investigación tradicional
en psicoterapia, centrada primordialmente en estudiar los resultados finales de ésta
(Elliott, 2010; Knobloch-Fedders, Elkin, & Kiesler, 2015). Se argumentaba que, si
bien esta tradición había dado pruebas irrefutables de la efectividad de la psico-
terapia, su conclusión de que no existían diferencias en el efecto de distintos
enfoques terapéuticos no aportaba a entender el fenómeno del cambio. En
respuesta a lo anterior, la investigación de proceso propuso examinar los ‘momen-
tos’ específicos de la terapia que fueran relevantes para el cambio, así como sus
componentes y los mecanismos que facilitarían su ocurrencia (Greenberg, 1986;
Safran, 2003). Esta aproximación a la investigación consideró que estos momen-
tos, así como sus componentes, podrían varían a lo largo del curso de la terapia y
en relación a los distintos contextos en que tendrían lugar (Greenberg, 1986). De
acuerdo a esta visión, el proceso psicoterapéutico se entendería como una secuen-
cia de estados recurrentes y de transiciones entre ellos, revelados en patrones y
expresiones identificables (Safran, 2003).
Si bien la investigación del proceso psicoterapéutico ya ha generado un
importante corpus de conocimiento, en la actualidad está recibiendo un impulso
adicional, que responde a la creciente convicción de que aquélla investigación que
se centra exclusivamente en los resultados de la psicoterapia parece haber agotado
su vida útil. Esta convicción se refleja en los argumentos esgrimidos desde el
National Institute of Mental Health (NIMH) [Instituto Nacional de Salud Mental]
de Estados Unidos (2008), en que se aprecia reticencia a seguir invirtiendo
recursos en estudios comparativos de psicoterapia que solo enfatizan los resulta-
dos finales de los tratamientos psicoterapéuticos. Este argumento se sostiene en
tres razones: (a) la eficacia de la psicoterapia está acreditada (Smith & Glass,
1977), (b) 40 décadas de investigación han comprobado que los diversos enfoques
terapéuticos no se diferencian en cuanto a su efectividad, y (c) los estudios
centrados únicamente en los resultados no aportan nada nuevo a la comprensión
de por qué la terapia es efectiva. Es por ello que actualmente resultaría crucial
invertir los recursos investigativos en aumentar los estudios de proceso.
En esta primera parte de la introducción del número especial hemos abordado
algunos aspectos definitorios y hemos delineado aspectos contextuales involucra-
dos en el nacimiento de la investigación de proceso en psicoterapia. Si bien hemos
mencionado algunos hitos importantes del contexto de su desarrollo, es el primer
artículo de este número especial, del autor Adam Horvath (2016), el que nos
ofrece información detallada sobre su evolución. A través de un inspirador relato,
el autor hace un recorrido histórico de la investigación de proceso y la sitúa en el
contexto de la historia más global de la investigación en psicoterapia, explicando
su desarrollo a partir de las limitaciones del paradigma predominante previo,
mayoritariamente centrado en los resultados. Por otro lado, el artículo también
rescata las tendencias actuales en los programas de investigación del proceso
terapéutico que constituyen esta línea de indagación.
214 M. Krause and C. Altimir
Acknowledgments / Agradecimientos
The authors gratefully acknowledge the support by the Fund for Innovation and
Competitiveness (FIC) of the Chilean Ministry of Economy, Development and Tourism,
through the Millennium Science Initiative, Grant N° IS130005. Las autoras agradecen el
apoyo del Fondo de Innovación para la Competitividad (FIC) del Ministerio de
Economía, Fomento y Turismo, a través de la Iniciativa Científica Milenio, Proyecto
IS130005.
Disclosure statement
No potential conflict of interest was reported by the authors. / Los autores no han referido
ningún potencial conflicto de interés en relación con este artículo.
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