Historical Paths in Psychotherapy

Research 3
Diana Braakmann

Contents Abstract
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 The history of psychotherapy research can be
3.2 The Phases of Psychotherapy Research . . . 40
viewed on the basis of four phases that differ
3.2.1 Phase I (1920 to the Birth of Psychotherapy in general streamings, aims, achievements,
Research in 1954) and Some Events and protagonists, respectively. In the first
Much Earlier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 phase (1920–1954), phenomena of private
3.2.2 Phase II (1955–1969): The Second Attack
and the Advancement of Process Research . . . 43 practices became objects of scientific investi-
3.2.3 Phase III (1970–1983): Refinement and gation and basic outcome research was
Challenge of the Mainstream . . . . . . . . . . . . . . . . 47 “invented.” The first systematic sound
3.2.4 Phase IV (1984 to Now): Discovery and recordings by Carl Rogers and his team
Micro-dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
represented the roots of process and process-
3.3 The Birth and Development of Common outcome research. In the second phase
Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
(1955–1969), pre-post-follow-up designs
3.3.1 The Origin: Saul Rosenzweig . . . . . . . . . . . . . . . . 55
3.3.2 The Medical Model vs. the were developed. Process research was inten-
Contextual Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 sively advanced and questions were posed in a
3.3.3 The First Common Factor Model and a Gap more complex way. The refinement of
of References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
research questions and further development
3.3.4 The Very First Panel on Common Factors:
Fitness of Interpretations vs. Correctness . . . . 57 of methods—especially meta-analytic stra-
3.3.5 Evidence for Common Factor Models . . . . . . . 57 tegies that allowed summarizing a large
3.3.6 Integrative Approaches . . . . . . . . . . . . . . . . . . . . . . . 59 body of information across outcome stud-
3.4 Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . 59 ies—were major achievements of phase III
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
(1970–1983). The fourth phase (1984 to
now) is characterized by an intensive deepen-
ing of process and process-outcome research
and by the emergence of mixed-method
approaches, the investigation of unsuccessful
cases, intercultural issues, as well as client and
therapist factors and their interaction. Com-
mensurate with the enormously quick increase
of the importance of the Internet in everyday
D. Braakmann (*)
life, settings of online psychotherapy became
Department of Psychotherapy Science, Sigmund Freud a matter of interest. With respect to the enor-
University, Freudplatz 1, 1020 Vienna, Austria mous influence the idea of common therapy
e-mail: [email protected]

O.C.G. Gelo et al. (eds.), Psychotherapy Research, 39

DOI 10.1007/978-3-7091-1382-0_3, # Springer-Verlag Wien 2015
40 D. Braakmann

factors that can be observed across all thera- aims, which differ between the phases. In gen-
peutic school settings has won in psycho- eral, there have been two major traditions in
therapy research, a second chapter is psychotherapy research that have caused a lot
dedicated to a detailed view on the “birth” of friction and are still controversial today,
and further research developments in this namely, the one being characterized by logical
field. The concluding paragraph offers a positivism and operationalism and the other by
short glance on possible future perspectives. structuralism, phenomenology, and herme-
neutics (see Ponterotto 2005 and Chap. 4; see
also Gelo 2012). The two traditions especially
differ in their epistemological pre-assumptions
and have been challenged frequently during the
3.1 Introduction
last decades. Today there are increasingly more
attempts to combine the approaches, to aim at
The historical traces of psychotherapy research
synergetic effects, and to take a position of
are an essential and necessary context for the
methodological plurality (Muran et al. 2010).
understanding and further development of psycho-
therapy research today. Therefore a chapter in a
handbook on psychotherapy research needs its
3.2.1 Phase I (1920 to the Birth
introduction from a historical perspective. The
of Psychotherapy Research
history of psychotherapy research has been
in 1954) and Some Events
described by several authors (e.g., Lambert
Much Earlier
et al. 2004; Muran et al. 2010; Orlinsky and
Russel 1994; Strupp and Howard 1992). The pres-
In general, the main concern of the first phase
ent chapter aims at providing the reader with
was “to demonstrate the feasibility and necessity
information on the historical phases of psycho-
of applying scientific methods to the study of
therapy research, as they have been already
psychotherapy” (Orlinsky and Russel 1994,
differentiated by Orlinsky and Russel (1994).
p. 191). The beginning of the first phase is mainly
As to the very early roots, the chapter widens the
described from the 1920s on, but there are even
view and goes beyond the beginning in 1920.
some earlier roots we should not forget.
Streamings and paradigms will be described as
well as the role of key persons who affected the
3.2.1.1 Nearly Forgotten Roots
development and whose achievements still radiate
and Famous Ones
today on the field of psychotherapy research and
Hardly anyone would expect the very first
its dynamics. The birth and advancement of the
publications of systematic reflections on psycho-
idea of common factors is dealt with in detail with
therapeutic methods to be even enrooted in the
respect to its timeliness.
eighteenth century. Indeed, it was more than
100 years before Hippolyte Bernheim
(1840–1919) introduced the term “psychotherapy”
3.2 The Phases of Psychotherapy (Bernheim, 1892), see when Karl Philipp Moritz
Research (1756–1793), a philosopher, writer, and teacher,
founded the Journal Erfahrungsseelenkunde or
This chapter is structured by the idea of four Journal of Psychology from Experience. The peri-
phases of the history of psychotherapy research, odical was created as a reader for scholars and
being proposed by Orlinsky and Russel (1994). non-scholars and was published up to 1792. It
Although the division states an oversimplifica- provided the possibility to everyone who was
tion of the history, it provides boundaries that interested to publish knowledgeable observations
facilitate the description and understanding as and thoughts on issues of mental disorders and
well as distinguishing between streams and the respective treatment options of that time.
3 Historical Paths in Psychotherapy Research 41

Many contributions focused on questions of how viewed as a major milestone of the reentry into
to understand mental disorders more deeply but outcome as well as process research interests
also how affected authors cured themselves after the war (Strupp and Howard 1992). In gen-
(Fiedler 2010). eral, central concerns of psychotherapy research
The better-known origins of psychotherapy in the 1950s included patient and therapist
research are the Studies on Hysteria by Breuer characteristics, process of psychotherapy, and
and Freud (1895). They contained a number of common treatment factors but also possible
case studies reflected from a neurophysiological limitations of psychotherapy that were increas-
and psychological point of view. As it appears ingly perceived and observed.
during the early stages of clinical sciences, the
very first research steps were done in the form of
3.2.1.3 The Catalyst Effect: Eysenck
single-case studies that provided the first evi-
The proliferation of uncontrolled and also anec-
dence for theories and practice of psycho-
dotal clinical case studies at the beginning of the
therapies. Freud’s analytical hypotheses were
1950s became increasingly criticized in favor of
mainly supported by clinical case studies, which
more systematic clinical surveys with increasing
are especially applicable to deeply exploring the
sample sizes and also experimental investi-
therapeutic process and generating new hypo-
gations due to historical trends and important
theses to be investigated more systematically
events (Hersen et al. 1984)—one of them
(Hersen et al. 1984). To date, it is still difficult
undoubtedly being H.J. Eysenck’s attack on the
to understand why it was not until the 1990s (e.g.,
effects of psychotherapy in general. He
Faller and Frommer 1994) that case studies
provocatively asserted that empirical research
really had their renaissance in the field of psy-
did not support the claim that psychotherapeutic
chotherapy research, except for the maintenance
approaches were more efficacious than neutral
of more anecdotal case studies in the meantime.1
(control) conditions and that recovery of psycho-
pathology was just reflecting spontaneous remis-
3.2.1.2 The Early Beginning from sion rates (Eysenck 1952). One early rejoinder
the 1920s to the 1950s was Lester Luborsky’s rebuttal (Luborsky 1954)
Between 1920 and 1940 there was a slow but that stressed flaws in Eysenck’s control group
steady rate of publications, with a discontinua- and in the assessment of outcome. Eysenck’s
tion during the war (Orlinsky and Russel 1994). provocation evoked a challenging starting point
In the 1930s, institutions started outcome of the career of young Luborsky (Crits-Christoph
research activities by documenting treatment et al. 2010). In the same year Rosenzweig (1954),
results. The studies were mostly comprised of in his reply to Eysenck, criticized the different
simple tallies of therapist-perceived improve- standards of severity of illness and standards of
ment. After the war research activities reoccurred recovery in his empirical data. He evaluated
in the beginning of the 1950s, aiming at Eysenck’s comparison to be of little validity
investigating the many facets of psychotherapy. and his generalizations to be highly questionable
The Menninger Psychotherapy Project (see also because of low resemblance in the named
Sect. 3.2.2.6) started in the mid-1950s and can be standards for the experimental and control
group. Nevertheless, Eysenck’s attack had an
immense catalyst effect on the further develop-
ment of psychotherapy research in general, espe-
cially aiming at refuting his assertions, and
1
Obviously, the reason is that the development of psycho- therefore justifying the discipline, as will be
therapy research in the beginning happened in accordance described later in this chapter.
with the imperatives of logical positivism that considers
single-case research as marginal and consequently
excludes it.
42 D. Braakmann

3.2.1.4 The Roots of Outcome Research of the 1950s, for the very first time, sound
3.2.1.4.1 Counting and Statistics recordings of therapy sessions were applied as a
Thirty years after the Studies on Hysteria, the means of a scientific approach to psychotherapy.
first statistics-based outcome studies were The beginning of systematic phonographic
published in the late 1920s (Fenichel 1930, recordings of sessions can be viewed as the root
cited in Bergin 1971; Huddleson 1927; Matz of process research, invented and inspired by
1929). A very early British work by Neustatter Carl Rogers and his team at the Ohio State Uni-
(1935) was even published in the Lancet, which versity (Rogers 1942b). “The Case of Herbert
has continued to be one of the most influential Bryan” was the first fully transparent (through
journals in the field of medical research until transcriptions) psychotherapeutic case ever
today. This is astonishing, since still today, hav- published (Rogers 1942a). With this innovation,
ing a psychotherapy research study accepted by Rogers and his team tried to find an approach to
the evaluators of this journal is a difficult and illuminate the arcane characteristics of thera-
demanding task. Until 1940 the efforts focused peutic sessions (Rogers 1942a). Classifications
on very elementary outcome research aimed at a of therapist responses (e.g., questions, giving
status of scientific legitimacy. Most of the studies information, interpreting) or categorizations of
dealt with therapist-perceived improvement, “directive” vs. “nondirective” therapist behavior
diagnoses were vague, and samples were hetero- were made in the beginning. The very first
geneous and small (Bergin 1971). Therefore, sequential process research study was accom-
they did not allow for deep interpretations or plished by Snyder (1945) under the supervision
broad generalizations. The efforts were of Rogers. Both client and therapist responses
intensified after Eysenck’s provocative attack were rated, and which therapist behavior
on the efficacy of psychotherapy, as mentioned prompted which client reaction was traced.
above (Eysenck 1952). Psychometric scaling was Among other results, Snyder found that simple
used as a means of quantifying phenomena, after acceptance and clarification of feelings led to a
Thorndike (1918) had formulated much earlier, higher degree of client insight than questions and
“Whatever exists at all, exists in some amount. interpretations by the therapist (Elliott and
To know it thoroughly involves its quantity as Farber 2010).
well as its quality” (p. 16). He thereby took an Given the pioneer status, Rogers’ significant
acerbic position of positivism, which was heavily contributions were a strong emphasis on the
criticized in later stages of the development of importance of research in psychotherapy as well
the field of psychotherapy research. as the attempt to investigate the factors that con-
stitute an effective therapeutic treatment. In this
way, Rogers and his team (Gordon et al. 1954)
3.2.1.5 The Roots of Process and invented a new genre of research—the process-
Process-Outcome Research outcome research—with its main characteristic
3.2.1.5.1 The Revolution: Sound Recordings being the sampling of key therapy process
and Sequential Process Research variables used to predict post-therapy outcome
The striving for scientific legitimacy of psycho- (Elliott and Farber 2010).
therapeutic treatments was consistent with an
inherent characteristic of psychotherapy and its 3.2.1.6 Major Developments and
representatives, viewing psychotherapy as Achievements
corresponding to applications of science of the As a main achievement the protagonists of the
mind. This means at the same time a theoretical first phase showed that phenomena in private
allegiance to the ideal of natural science, follow- practice became objects of scientific investiga-
ing the logical positivism paradigm (i.e., objec- tion. Outcome research that was very basic in the
tivity, replicability, etc.) (Orlinsky and Russel beginning was especially refined after Eysenck’s
1994). As a revolution in psychotherapy research attack. Studies of this kind still strongly relied on
3 Historical Paths in Psychotherapy Research 43

a (post)positivistic model of science and empiri- state than ten years before, there was still not
cal investigation. Moreover, the introduction of enough solid evidence concerning the general
sound recordings meant the first sparks to the efficacy of psychotherapy to clearly refute
later and still current fireworks of process and Eysenck’s assertions. A key event was Bergin’s
process-outcome research, lighting the darkness (1963) review and scrutiny of data that Eysenck
of the therapeutic session. leaned upon heavily in support of his pessimistic
position expressed in the first and second attack.
From today’s perspective it can be viewed as a
3.2.2 Phase II (1955–1969): The turning point in the altercation. The surprising
Second Attack and the part of Bergin’s results was the observation that
Advancement of Process therapists could be divided into two groups: one
Research producing positive and another producing nega-
tive results. Therefore, the calculated mean of the
Immense growth in the field of psychotherapy effects had produced a parameter that seemingly
research could be observed from the middle of supported the assertion that psychotherapy was
the 1950s. The major task of this period can be uniformly not effective. The publication of this
described as fulfilling the promise of building a reanalysis in the Journal of Counseling Psycho-
scientific field of the study of psychotherapy logy stated a milestone for refuting Eysenck’s
(Orlinsky and Russel 1994). A second attack attack (Hersen et al. 1984). A flood of research
conducted by Eysenck (see Sect. 3.2.2.1) again activities on therapist variables was triggered,
had a catalytic impact on the field and stimulated which, among other topics, also investigated the
many of new investigations. This impetus was performance of lay persons (e.g., Rioch
also accompanied by a general, greater concern et al. 1965) and paraprofessionals (e.g., nurses;
with efficacy of psychotherapy by researchers Tharp and Wetzel 1969), being trained, for
(Hersen et al. 1984). It shaped in a way the example, for behavior modification.
pursuit of mostly outcome ideas, because general
justification was demanded to help psycho-
therapy to gain an acknowledged position in the 3.2.2.2 Justification Informed by Logical
scientific field and society in general. The second Positivism
phase was therefore very much characterized by The prevailing philosophy of science at the
the aim of justifying the psychotherapeutic pro- beginning of this period was still logical positi-
fession through research. Moreover, this phase vism with the focus on overt behaviors (referring
was characterized by a proliferation of process to observable aspects of behavior like aggression
studies, especially by client-centered researchers, or anxious avoidance). Subjective states in this
aiming at the validation of Rogers’ necessary and context were mainly considered as objectively
sufficient factors for therapeutic change (Rogers unverifiable, and the role of observers was under-
1957). stood as scientifically trustworthy (Anchin
2008), which from a current point of view, of
3.2.2.1 Eysenck’s Second Attack course, has to be heavily criticized and viewed as
In the 1960s psychotherapy researchers were insufficient to achieve deep knowledge about
again facing a difficult situation, when Eysenck changes in experience and behavior. Since a
repeated his provocative thesis, with a second main concern in the second phase was justifi-
attack referring to (seemingly) more supportive cation, nomothetic group designs and respective
data than in 1952 (Eysenck 1960). Although the statistical analyses were major elements of the
body of knowledge in psychotherapy research predominant methodology approaches in process
had already grown significantly and especially and outcome research, although they did not
research questions and associated methods had necessarily reflect the researchers’ personal
reached a much more elaborate and sophisticated convictions and interests.
44 D. Braakmann

3.2.2.3 Initial Conferences and The growth of the field revealed the need for
Reorganization of the Field new organizational structures that resulted in two
3.2.2.3.1 Initial Conferences split branches: On the one hand, the provisions of
Three initial conferences in 1958, 1962, and Kenneth Howard and David Orlinsky found their
1966 caused significant interest in psychotherapy culmination point in the first meeting of the Soci-
practice and research all over the world. The ety of Psychotherapy Research (SPR) in 1970 in
venues were Washington, D.C.; Chapel Hill; Chicago (Muran et al. 2010). On the other hand,
and Chicago, respectively. They were organized ten behavioral therapists (John Paul Brady,
by the American Psychological Association Joseph Cautela, Edward Dengrove, Cyril Franks,
(APA) and financed by the National Institute of Martin Gittelman, Leonard Krasner, Arnold Laz-
Mental Health (NIMH). The major aims of the arus, Andrew Salter, Dorothy Susskind, and
very initial conference were a) the evaluation of Joseph Wolpe) founded the Association for the
the state of the art of psychotherapy research and Advancement of Behavior Therapy (AABT) in
b) the stimulation of research. Significant partici- 1966 in Washington, D.C. (Franks 1987, 1997).
pants like Lester Luborsky, Jerome Frank, According to the development of behavior ther-
Joseph Matarazzo, Morris Parloff, Carl Rogers, apy and its discourses during the following
and Hans Strupp exchanged their ideas with decades, the AABT was renamed twice, which
colleagues, and the proceedings were published resulted in the current name the Association for
by Rubenstein and Parloff (1959). Behavioral and Cognitive Therapies (ABCT).
The two following conferences hosted the full The parallel development of the two branches
range of representatives of the psychotherapeutic symbolized a splitting of the field of psycho-
schools. Clinicians discussed theory and therapy research, mostly due to differing clinical
concepts as well as methodology, aiming at theories and their effect on research models.
elaborating and refining psychotherapy research Although the gap was maintained over decades
(Strupp and Luborsky 1962; Shlien et al. 1968). and can sometimes still be sensed today, both
The results were significant for the community “sides” show their commitment to bridge the
for many years, also supporting independent gap, aiming at synergies and fruitful cooperation
researchers by providing them with a significant for the further development of the psychotherapy
amount of knowledge and proceedings as well as research field in general.
inspiration for research ideas.
3.2.2.4 Outcome Research in Phase II
3.2.2.4.1 Controlled Experiments, Tests,
3.2.2.3.2 Reorganization of the Field and Interview Techniques
Another major development influenced the field The activities of outcome research in this phase
of psychotherapy research in the 1960s: the were closely linked to the necessity of producing
upcoming behavior therapy. The yearly chapters convincing rejoinders to Eysenck’s provocative
of The Annual Review of Psychology on psycho- statements. Although some behaviorally oriented
therapy reveal that at the latest 1965 behavior researchers used single-case experimental
therapy was viewed as a new force in the field designs to support the influences of their treat-
(Hersen et al. 1984). Unfortunately, at that time ment methods (e.g., Baer et al. 1968), a major
integration of these two existing psychotherapy portion of research activities focused on the
research fields seemed to be nearly impossible refinement and application of controlled experi-
because of differing clinical theories and their ments, aiming at proving the efficacy of psycho-
consequences for research approaches, although therapeutic interventions compared to control
it might have had a very fruitful effect on the conditions. Major developmental steps were
general development of research activities. therefore a consequence of the context of justifi-
Hence, during the following years the develop- cation. Quasi-experimental pre-post-follow-up
ment of the two research branches seemed to be designs (without randomized assignment to clini-
still quite distant from another. cal groups) were the predominant design,
3 Historical Paths in Psychotherapy Research 45

comprising assessments of personality and psy- development of approaches toward time sam-
chopathology as outcome variables (Orlinsky pling (e.g., a proportion of the beginning, middle,
and Russel 1994). For this purpose, tests and and end of the process). The calculation of
interview techniques had to be elaborated, averages served as estimation for specific aspects
modified, or newly developed. of the process. Unfortunately, process indices
Analogue research designs were quite promi- often seemed to be far from clinical experiences
nent, which means that researchers became inter- and the underlying theoretical pre-assumptions,
ested in contrived or simulated therapy but nevertheless stated an important approach,
situations. For example, patient samples with which provided a basis for the development that
mild clinical problems (i.e., snake phobia) were followed (Orlinsky and Russel 1994).
treated by trained graduate students (Lang and The 1960s were dominated by client-centered
Lazovik 1963). On the one hand, the application researchers. They primarily tried to validate
of these studies fostered the shift from survey Rogers’ necessary and sufficient conditions for
research to quasi-experimental controlled therapeutic personality change (Rogers 1957). A
designs (i.e., because of design economy and paradox could be observed in this context: While
avoidance of ethical constraints), and on the emphasizing the importance of the clients’ expe-
other hand, it was heavily criticized for removing rience, he made use of nonparticipant-obser-
studies too far from the clinical situations vational measures (at least partly based upon
(Hersen et al. 1984) to allow any meaningful the bias of positivism). These measures were
conclusions for the psychotherapeutic practice. mostly therapist ratings of client behavior in the
With respect to the complexity of the therapeutic sense of, for example, greater integration, fewer
process from today’s point of view, single- internal conflicts, or changes toward more
controlled experiments are not appropriate to mature behavior. Independent from this critique,
demonstrate the efficacy of psychotherapeutic the work of Rogers and his team stressed the
treatment approaches. Nevertheless, the merits relevance of the therapeutic relationship factors
of researchers of that time remain unquestion- and made a great effort to investigate them in a
able, taking into account their dependency on comprehensive and detailed way. Later, from the
the state-of-the-art methods on the one hand middle of the 1970s, a decrease of this specific
and being confronted with major pressure to jus- kind of work could be observed.
tify the field of psychotherapy in general on the
other hand. 3.2.2.6 Process-Outcome Research
in Phase II
3.2.2.5 Process Research in Phase II 3.2.2.6.1 The Menninger Project
3.2.2.5.1 Sound Recordings and As to the field of psychoanalysis, in the
Nonparticipant-Observational mid-1950s Karl Menninger, an American psychia-
Measures trist and founder of the Menninger Clinic, initiated
The development of formerly so-called objective an impressive 30-year longitudinal process-
measures for the analysis of sound recordings outcome study to investigate the psychoanalytic
made important progress for process research, treatment of 42 patients, supported by talented
which was still conducted quantitatively. For investigators like Robert Wallerstein, Otto
instance, the counting of self-references in the Kernberg, Lester Luborsky, and others. The defi-
verbal behavior, thought units, and chronological nite closure of this huge project was marked by the
periods were analyzed in the sense of process publication of Forty-Two Lives in Treatment: A
variables. In addition, Rogers traced clients’ the- Study of Psychoanalysis and Psychotherapy
matic patterns across sessions and change in (Wallerstein 1986). Mainly, two questions were
clients’ sense of self as matters of interest (Elliott addressed during the research process: What
and Farber 2010). The collection of immense changes take place in psychotherapy, and how
amounts of recorded sessions led to the necessary do those changes come about? The investigation
46 D. Braakmann

was realized by taking three major cross-sectional understanding of the role of the rationale is based
perspectives (“initial, termination, and follow-up upon more general psychological mechanisms
study”). In addition, the patients’ personality (e.g., Nelson and Borkovec 1989).
organization and life situation (in the sense of
outcome variables) as well as the therapeutic pro- 3.2.2.7 Client and Therapist Factors: More
cess were taken into account. Various additional Questions
publications arose from the Menninger Project, The crossing from phase I to II was characterized
dealing with facets of the study like psychological by interests in the role of client characteristics.
testing (Appelbaum 1977), the role of situational The great variety of dimensions of interest
variables, factor-analytic aspects (Kernberg included age, sex, race, education levels, reli-
et al. 1972), and individual prediction of thera- gious affiliation, motivation, insight or defensive-
peutic success (Horwitz 1974). ness, and many more. In addition, differences
between clients with regard to their develop-
3.2.2.6.2 More Ingredients of the Process mental experiences, personality organization,
Besides relating client and therapist variables to social skills, and resources were taken into
outcome of psychotherapy (see Sect. 3.2.2.7), account (Hersen et al. 1984). The potential
there was an intense interest in analyzing alter- mediating or moderating effects of the socio-
native elements that might characterize the psycho- economic status on the efficacy of psychotherapy
therapeutic process. Some studies focused on ideas were investigated and became a leading idea of
of verbal reinforcement, referring to the idea— more complex outcome studies (Rosenthal and
derived from learning theory—that therapists (not Frank 1958). On the whole in this period’s results
necessarily consciously) could shape their clients’ remained contradictory, and numerous new
behavior through selective reinforcement of behav- questions were raised.
ior patterns or the choice of topics being dealt with Difficulties in identifying significant client
in sessions. In this context, transcripts of sessions predictors influenced a growing interest in the
conducted by Rogers were also analyzed by Truax relation between therapist characteristics and
(cited in Truax and Mitchell 1971, Hersen outcome. For instance, therapist psychopatho-
et al. 1984). They revealed, for example, that the logy was found to inhibit efficacy of psycho-
selective use of empathy and warmth as reaction to therapeutic outcome (Bandura et al. 1960; Holt
a client’s reports and behavior seemed to follow and Luborsky 1958). The 1950s resulted in pos-
such a shaping behavior. In this context, also psy- ing questions rather than giving comprehensive
choanalytic interpretations were shown to rein- empirical answers. One main conclusion from
force client responses independent from their single studies was that more complex models
accuracy (Noblin et al. 1963). This finding is gen- were needed that entailed interaction and combi-
erally related to the current evidence-based nation of client and therapist characteristics,
assumption that a rationale itself is understood as leading to a great variety and amount of
a common factor within the complex psychothera- process-outcome research efforts in the follow-
peutic process because it offers a plausible expla- ing decades.
nation for psychological problems and a prognosis
for how to change it (Frank and Frank 1991; 3.2.2.8 Differences and Common Ground
Wampold 2001). Therefore, the usage of a ratio- These examples mentioned above were challeng-
nale is accompanied by hope and positive ing peaks of the phase, which somehow sepa-
expectancies in clients, independent from the rated researchers from another, differing in their
theory it is based upon. Nevertheless, the former beliefs about which elements influence the psycho-
and the current results differ in their ideas about therapeutic process and outcome and to what
the respective mechanisms of change: The expla- extent. These beliefs were (and still are) closely
nation of research results in the 1960s was linked to the respective metatheories of psycho-
rooted in learning theories, whereas the current therapy. There was a huge amount of research
3 Historical Paths in Psychotherapy Research 47

activities taking place on a more common ground the communication of therapists and clients
for the community. Their main commonality was (Saslow and Matarazzo 1962). Moreover, pro-
the enterprise to understand and improve psycho- cess research was advanced in a very energetic
therapy through the identification of key elements and fruitful way (Orlinsky and Russel 1994).
like the therapeutic relationship, client and thera- This means that the promise of building up a
pist variables, as well as their match and inter- scientific field was fulfilled with success, inde-
action and relating them to outcome variables pendent of the fact that still major developments
(Butler 1952; Strupp 1957; Truax and Carkhuff and changes were expected and were self-
1965; Truax 1968; Hagebak and Parker 1969). evidently viewed as eligible.
These ideas were ancestors of what we consider
today “common factors.” The consistent labeling
as such in the community started with the formu- 3.2.3 Phase III (1970–1983):
lation of the first explicit common factor model by Refinement and Challenge
Frank (1961). of the Mainstream

3.2.2.9 Major Developments The tasks of the third period were the expansion
and Achievements and refinement within the methodological main-
3.2.2.9.1 Goodbye Simplicity: Complex stream of process and outcome research. The
Relationships Between Process experimental mainstream was elaborated and
and Outcome further developed (Orlinsky and Russel 1994).
Retrospectively, one might complain about the The main achievement was the convincing
naivety of merely considering quantitative vari- answer to Eysenck’s criticism that clearly said:
ations in treatment in that time, but studies had Psychotherapy works! Meta-analyses as a new
pilot status, in the sense that they stated initial statistical technique provided the researchers
steps that resulted in more refined and systematic with the possibility to ascertain the general
research. value and utility of psychotherapy (Smith
The results suggested a complex relationship et al. 1980, see Sect. 3.2.3.3). Process and
between process and outcome instead of simple process-outcome studies were designed in a
linear relations that had been assumed before, renewed way, including new concepts and
and therefore stated a call to further investigate methods (e.g., Gomes-Schwartz and Schwartz
this complexity in the future. 1978; O’Malley et al. 1983; Mintz and Luborsky
One achievement was the development of 1971).
pre-post-follow-up designs, conducted by The publication of the first Handbook of
means of elaborate measures, interview tech- Psychotherapy and Behavior Change (Bergin and
niques, and tests. These steps can be viewed as Garfield 1971) amazingly summarized the new
(forced) appropriate answers and rejoinders to variety of actions and streams in the community.
Eysenck’s criticism. Subsequently, it is not by The significance of this opus for communicating
chance that a list of “landmark volumes in psycho- progress and development in psychotherapy
therapy research” being reviewed and compiled research is outstanding and unquestionable, readily
by Orlinsky and Russel (1994, pp. 187–190) integrating new streams into the body of knowl-
contains titles with terms like “evaluation,” edge. The current version is already in its 5th
“effective psychotherapy,” or “outcome.” edition (Lambert 2004).
At the end of the 1950s, questions began to be Generally, researchers felt freed from the
posed in a growing, elaborate, and complex way, necessity of exclusively justifying and offered
and also methods and techniques got more much more variations of research questions.
sophisticated. Simple case studies paled in favor The emphasis on the psychotherapeutic process
of (many analogues) experimental controlled as well as on issues like “psychotherapy in the
studies using elaborate techniques for assessing ghetto” (Richter 1974), “the lives of
48 D. Braakmann

psychotherapists” (Henry et al. 1974), and the communication was outstandingly supported by
“therapeutic discourse” (Glaser 1977; Gross the creation of the Society for Psychotherapy
1978) revealed a more playful and creative Research (SPR) in 1970 and the Advancement
approach to the choice of issues, instead of of Behaviour Therapy (AABT) in 1966, which
being forced to work solely on justification. highly met the needs of the research community.
The aims of the SPR were (and are still today),
3.2.3.1 Negative Effects among others, (a) to encourage the development
and Accountability of scientific research on psychotherapy; (b) to
In the 1970s researchers became concerned with foster the communication, understanding, and
the possible negative effects of psychothera- use of research results; and (c) to enhance the
peutic treatments (Bergin 1971; Goth social value and the efficacy of psychotherapy.
et al. 1980; Strupp and Hadley 1977). Bergin The community’s pursuit of an increasing
(1971) can be viewed as a pioneer who dealt methodological rigor had its impact on viewing
with this topic by reanalyzing cases with minor process and outcome research as two separate
changes in treatment outcome studies. The main fields, a kind of dichotomization, although there
reasoning was that if psychotherapy possesses already have been critical voices against this
the potential to effectuate positive change, the artificial separation (Orlinsky and Russel 1994).
same potential should be present in a negative
direction, subsequently a deteriorating impact 3.2.3.3 Outcome Research in Phase III
(Strupp et al. 1976). The explicit identification Once it was shown that psychotherapy works, the
and naming of negative effects of psychotherapy next idea was to find out if some therapeutic
would perhaps have caused difficulties in earlier approaches are potentially more effective than
justification stages of psychotherapy research, others. Moreover, the proliferation of different
although of course there already had been aware- therapeutic models taking place in the third
ness in the community for the importance of phase prompted the increasing accomplishment
respective topics. The issue can therefore be of comparative outcome studies. In particular,
seen as a sign of more freedom in designing the ambitions for the design of randomized con-
research field. This might also have been trolled trials (RCTs) emerged. In general, out-
associated with an increase of topics chosen come research by that time was characterized
because of personal epistemological interests of by keeping up the ideal of controlled conditions
clinicians and researchers, but this has to be and a growing interest in the use and investi-
viewed as hypothesis. gation of manualized treatments.
The associated issue of accountability also From the 1970s onward, psychotherapy
became a key consideration for psychotherapists research adopted RCT design from pharmaco-
and researchers in the 1970s, most probably with logical research as the new ideal of psycho-
the greatest impetus toward issues associated therapy research (Desmet 2013). The main
with governmental agencies and insurance differentiating characteristics of RCTs (also
carriers. Under deteriorating economic condi- referred to as efficacy studies) compared to
tions, third-party payers got more concerned quasi-experimental designs are the randomized
with the efficacy of psychotherapeutic treatments assignment of participants to experimental and
offered to patients (Hersen et al. 1984). control groups and the accomplishment of the
trials under extremely controlled conditions.
3.2.3.2 The Scope of the Community The critique from today’s point of view focuses
As already mentioned, this phase was very on ethical troubles as well as a tremendous gap
important for the scope of the community between research and practice being caused by
in a concrete sense, because the collegial RCTs. Instead, naturalistic effectiveness studies
3 Historical Paths in Psychotherapy Research 49

in the form of quasi-experimental design are They are combined in a formula aiming at
fostered as an alternative. increasing the probability that different evalu-
ators will come to the same conclusion. The
3.2.3.3.1 The Treatment of Depression first analysis of 475 studies (Smith et al. 1980)
Collaborative Research Program proved the superiority of psychotherapy to no
The launch of the Treatment of Depression treatment and treatment control conditions with
Collaborative Research Program (TDCRP) (e.g., effect sizes of up to .85. Although in a later
Elkin 1994; Elkin et al. 1989), coordinated by Irene reanalysis the effect size in the same data set
Elkin, represents a very meaningful methodologi- had to be relativized to .60 (Shadish
cal advancement in outcome research in psycho- et al. 1997), the results showed that psycho-
therapy. The uniqueness of the study for therapy without a doubt works. This meta-
psychotherapy research was realized by a collabo- analytic study and many other reviews came to
rative, multisite, controlled, comparative trial the same conclusion then drawn by Luborsky
design, investigating a large sample size. The et al. (1975), suggesting the equivalence paradox
effects of two manualized psychotherapeutic (Dodo Bird Verdict, 3.3.1) that states that all
treatments for depression, namely, cognitive ther- psychotherapies, regardless of their specific
apy (Beck et al. 1979) and interpersonal psycho- components, produce equivalent outcomes
therapy (Klerman et al. 1984), were precisely (Lambert and Ogles 2004).
investigated in an outpatient setting and compared The flourishing activities of the former phases
to the psychopharmacological effects. Besides the (especially phase II) were strengthened in their
comparative investigation, the TDCRP aimed at function as a rejoinder to Eysenck by their sum-
advancing psychotherapy research methods in a mary by means of statistical procedures. This
general way by determining the feasibility of the new period of outcome research provided the
multisite (collaborative) clinical trial design for the community with new research interests, e.g., in
field of psychotherapy. This design had been the effects of components of specific treatments2
widely used in psychopharmacological research and comparisons of alternative treatments for
before. Elkin tried to equilibrate the rigors of specific disorders. However, meta-analytic
research methods and the preservation of the com- strategies have been criticized by authorities of
plex human qualities of psychotherapy by creating the field (Garfield 1981; Wilson and Rachman
the opportunity to investigate many key theoretical 1983), particularly with respect to the possible
and practice-relevant questions about mechanisms biases and arbitrariness of the method, problems
of change to be investigated via precisely collected of clinical vs. statistical significance (see also
and archived TDCRP data beyond efficacy issues, Sect. 3.2.4.3), and shortcomings in the selection
which is an outstanding and admirable characteris- of studies.
tic of her achievements (Moras and Shea 2010).
3.2.3.3.3 Outcome Measures and Single-
3.2.3.3.2 Meta-Analytic Strategies
Case Experimental Approaches
Another major milestone in the field of outcome
A lot of attempts were made aiming at enriching
research was the development of meta-analytic
and professionalizing the field of outcome
strategies. These new statistical methods allowed
measures. Waskow and Parloff (1975) organized
the aggregation of the results of single investi-
a panel on outcome measures for the NIMH and
gations, aiming at proving the effects of psycho-
therapy in thereby summarized research fields.
The prior means of evaluating the effects of 2
This interest mainly implies an adherence to a medical
psychotherapy had been the calculation of box model of psychotherapy, which has to be differentiated
scores. This means simply counting outcomes for from a contextual model (Wampold 2010) (see Sect.
2.1.1), which presumes that a “surgical” subdivision of a
and against the (positive) effects of psycho-
treatment approach into its single elements is not possible
therapy. Rather than relying on simply adding because of the interaction and transaction of involved
results, meta-analyses calculate effect sizes. variables.
50 D. Braakmann

published a comprehensive outcome measure research and objective process research. Many
collection, comprised of variables rated by researchers claimed that solely research activities
patients, therapists, and significant others as connecting process with outcome variables can
well as independent clinical evaluator variables. really answer the question about the value of
Besides the measures themselves, they tried to psychotherapy. Process variables that showed to
heighten the precision of the process of choosing be quite robustly linked to therapeutic success
the clinically appropriate outcome measures. were, for example, the working alliance
Single-case experimental approaches were (or group cohesion in group sessions), patient
conducted in the field of behavior therapy in a openness vs. defensiveness, patient expressive-
more refined way than before (see Sect. 3.2.2.4), ness, or reciprocal affirmation (Orlinsky
providing a better control of confounding factors et al. 2004).
in comparative studies and permitting an analysis
of the vicissitudes of the treatment by the use of
3.2.3.4.2 Kiesler’s Influence: A Major
repeated measures during baseline and treatment
Methodological Advancement
(Hersen and Barlow 1976). A critical altercation
Kiesler assumed that the development and main-
with the methodological and interpretive
tenance of individuals’ patterns of behaving and
problems evolved at the same time, focusing on
experiencing are mainly influenced by inter-
problems like decisions on when to alter
personal relationships through patterned inter-
conditions in experiments, definition of evalu-
action styles. His book The Process of
ation criteria for treatments, and the clinical
Psychotherapy: Empirical Foundations and
significance of effects (Kazdin 1978).
Systems of Analysis (1973) more generally
communicated significant methodological
3.2.3.4 Process and Process-Outcome advances and the refinement of measurements
Research in Phase III in the field of process research without being
3.2.3.4.1 The Working Alliance exclusively circumscribed to alliance issues. It
Although the beginning recognition of process can be viewed as the equivalent to the outcome
research with focus on the complexity of phe- measure collection by Waskow and Parloff
nomena in psychotherapy already started in the (1975) (mentioned in Sect. 3.2.3.3) for the field
middle of the 1960s, this approach began to of process research.
really flourish in the third phase of psychother- Kiesler (1973, 1982a) created a new concep-
apy research. In the middle of the 1970s, Bordin tual and methodological basis for analyzing the
(1979) offered a reformulation of the therapeutic therapeutic relationship by developing an obser-
relationship, and the term “working alliance” vational system based upon his (nowadays more
(see Chap. 16) emerged and would not be than well-known) circumplex model. His work
changed until today. The working alliance was on this topic can be viewed as a constitutive
conceptualized as a construct with distinguish- milestone for process research, in the form of
able components; research activities intensively offering a comprehensive, precise theoretical
focused on this concept, including the construc- model, a circumplex providing an interpersonal
tion and application of new instruments in pro- circle taxonomy (Kiesler 1982), as well as
cess research. major methodological advancements, namely,
The preparatory period for the emergence of the development of the Impact Message Inven-
process-outcome studies as a specific field in tory (IMI) and Checklist of Interpersonal Trans-
psychotherapy research had already begun in actions (CLOIT). The IMI measures impacts
the 1950s (see Sect. 3.2.2.6). The flourishing of corresponding to the interpersonal circle cate-
process-outcome research in this phase depended gories and has been widely used in research on
on the prior development of systematic outcome interpersonal elements of depression, personality
3 Historical Paths in Psychotherapy Research 51

disorders, and other psychopathologies (Kiesler reasons: (1) The studies included problematic
2001b), whereas studies using the CLOIT rather diagnostic groups, (2) the process of remission
focused on interpersonal transactions in therapy was not explained at all, and (3) there is no
like metacommunication, patient-therapist support from learning theory that could explain
matching, countertransference, and therapeutic such a remarkably high spontaneous remission
alliance (Kiesler 2001a). rate that implies a deep change of attitudes and
Several years before, Kiesler (1966) had habit systems without any intervention (Kiesler
authored his famous article, “Some myths about 1966).
psychotherapy research and the search for a para- One example for the currency of the impact of
digm.” This publication summarized rejoinders Kiesler’s model on research and clinical practice
to Eysenck and designed the type of research that is the cognitive behavioral analysis system of
was needed to refute Eysenck’s provocations. By psychotherapy (CBASP), developed by James
delineating (among others) the “patient unifor- McCullough for patients suffering from chronic
mity myth” and the “therapist uniformity myth,” depression (McCullough 2005), which is based
he reasoned that the question “Does psycho- upon the theoretical basis of viewing, observing,
therapy work?” should be turned into “What and influencing the therapeutic relationship in
works for whom?” Based upon the idea that a the sense of Kiesler.
minimal but general common paradigm in As an anecdotal digression, it is worth men-
psychotherapy research should take into account tioning that Kiesler had quite painful experiences
current theoretical inadequacies and empirical in his role as a leading team member of Rogers’
learning, he suggested that subsamples of innovative process research project on the effi-
research groups should be grouped depending cacy of client-centered therapy for schizo-
on patient and therapist variables (e.g., experi- phrenia. He experienced emotionally escalating
ence, attitudes, and personality variables). scenarios as a consequence of nontransparent
Opposing the uniformity myths mentioned communication when a major problem with the
above, he referred to the idea that patients com- database occurred that heavily endangered the
pared to each other as well as therapists com- continuance of the project. Undoubtedly, these
pared to each other are more different than alike: experiences fostered his interests in the impact of
“Hence, my final point would be that before we can incongruent communication on interpersonal
validly assess the outcome or therapy evaluation problems (Wagner and Safran 2010).
problem, it is vitally necessary that we attempt to
isolate therapist dimensions that will accurately
reflect heterogeneity of therapist performance.”
(Kiesler 1966, p. 113)
3.2.3.5 Major Developments
and Achievements
Many years later, the Clinician’s Research The refinement of research questions and further
Digest identified this publication as one of 12 sig- development of methods in the sense of more
nificant articles in clinical psychology (Wagner concisely and detailed formulated issues can be
and Safran 2010). viewed as one of the major achievements of
Another fundamental contribution of Kiesler phase III. The development of meta-analytic
was the refutation of the spontaneous remission strategies allowed the summary of a large body
myth, stating a direct counterreaction to of information across outcome studies inside spe-
Eysenck’s claims (see Sect. 3.2.1.3). With great cific research fields. It thereby contributed to the
detail, Kiesler carves out that the base rate of two stability of evidence for the effects of psycho-
thirds of spontaneous remission in patients, therapy. Being freed from reduction to justifi-
stated by Eysenck based upon studies by Landis cation, the researcher utilized the newly won
(1938) and Denker (1947), and at the same time degrees of freedom to challenge mainstream
being the core of his line of argumentation, is approaches, especially in the field of process
questionable and invalid for the following and process-outcome research, and finally to
52 D. Braakmann

ask more creative questions and conduct the fur- has been focused and discussed (Elliott and
ther, associated developments of methods. Anderson 1994).
The major concern in the former three phases
had been the task to demonstrate that psycho-
3.2.4 Phase IV (1984 to Now): therapeutic interventions achieve significant
Discovery and Micro-dynamics positive effects compared to control conditions.
After this was successfully achieved, a second
3.2.4.1 From Verification to exigent question gained increasing weight:
Discovery Informed by How are the significant positive effects of psycho-
Constructivism-Interpretivism therapy achieved? This question was directly
The movement in the fourth phase until today connected to issues to process and process-
can mainly be described as a shift from verifi- outcome activities because the community had
cation to the context of discovery which is, realized solely that the connection of process
among other aspects, illustrated by the increasing and outcome variables would enable researchers
use of qualitative research. Shapes of process- to answer this question (see Sect. 3.2.3.4).
outcome relations in the sense of linear and non- Of course, the main question of how effects are
linear models of change represent a return of achieved implies loads of sub-questions, which
major interests to phenomena and exploration. certainly will still be dealt with during the next
Qualitative research may be generally framed decades. Moreover, critical discussions emerged
within the constructivist-interpretivist paradigm, on different philosophies of science and the
which developed as a consequence of the criti- associated methods as well as on issues of clinical
cisms to the dominant (post)positivistic para- significance and growth models. Therefore, this
digm. Its main roots are, among others, phase is also characterized by controversy and
philosophical hermeneutics, according to which fundamental critique.
meaning always emerges from a process of indi-
vidual understanding and is, therefore, inter- 3.2.4.2 The Shift of Paradigms
pretative, and phenomenology, according to In the fourth phase a relevant shift of paradigms
which investigation of subjective experiences is that were viewed to be legitimately applied in
considered to be possible only to the extent to psychotherapy research could be observed. The
which we are able to assume the first-person significant rise of qualitative psychotherapy
perspective of the subjects being investigated research was confirmed by the publication of
(see Gelo 2012; see also Rennie 2012; see also the special issues or sections on the subject in
Chap. 4). the Journal of Counseling Psychology (Hill
Client variables, therapist variables, system- 1994) and Psychotherapy Research (Elliot
atic treatment selection and placement, as well as 1999). Qualitative research in general aims at a
bridging the chasm between research and clinical deep understanding of human behavior, which
work are some topics that began to receive more especially asks the question of why people
attention in this phase. This development is behave in a certain manner. This means that
highlighted by Orlinsky and Russel (1994), by instead of verification and generalization, discov-
summarizing the essence of several authors’ ery is a major aim. This implies (a) a critical view
acknowledgment in Reassessing Psychotherapy on traditional quantitative research designs and
Research (1994) that “simplicity has seemed to (b) the advancement of new research paradigms.
have had its day” (p. 204). The role of context Despite the permanent but slowly increasing
variables is viewed as absolutely crucial, and the relevance of qualitative paradigms in psycho-
ambiguity of the communication between thera- therapy research, still a disbalance in favor of
pist and patient is stressed. The necessity of the quantitative approaches can be observed.
overcoming an oversimplifying view of the But a major stream and continuous development
methods needed to empirically investigate them aims at methodological pluralism in the sense of
3 Historical Paths in Psychotherapy Research 53

complementary approaches that in coexistence Another approach states the calculation of the
should make it more possible to meet the degree reliable change index (RCI; Jacobsen et al. 1984;
of complexity of phenomena that are dealt with Jacobsen and Truax 1991). The RCI is calculated
Lambert (2013). as a difference score (posttreatment minus pre-
treatment) divided by the standard error of
measurement, based upon the reliability of the
3.2.4.3 Outcome Research in Phase IV measure. The parameter has been widely used and
3.2.4.3.1 Skepticism Toward RCTs can be a valuable assessment of clinical signifi-
Researchers were faced with the problem that cance when used in conjunction with reliable
some treatments with evidence of efficacy gained measures and appropriate cutoff scores (Kendall
under controlled conditions did not prove effi- et al. 2004). Primary studies as well as meta-
ciency in naturalistic designs (Weisz et al. 1993). analyses reveal that many clients achieve clinically
Findings like these nurtured the skepticism meaningful changes, according to the two
toward RCTs, and outcome research had to be approaches. For example, a summary of 28 clinical
specified in the sense that naturalistic settings of trials by Hansen et al. (2002) yielded 58 % of the
research had to be heightened. This means a turn clients with clinical significant changes in outcome
from questions of efficacy to effectiveness. Effi- variables (Lambert and Ogles 2004).
cacy refers to research designs under systemati-
cally controlled conditions with internal validity
being paid most attention to. Effectiveness stud- 3.2.4.4 Process and Process-Outcome
ies instead investigate the impact of treatments Research in Phase IV
under “natural” conditions in the sense of clinical 3.2.4.4.1 Psychological Processes Instead of
settings, with external validity and generalization Diagnoses
being the most important quality marker (Lam- The major role of the assignment to diagnostic
bert and Ogles 2004). categories in research designs began to be criti-
cized during phase IV. The single classification
of individuals in the sense of mental disorders,
3.2.4.3.2 Statistical vs. Clinical Significance
including labeling them with diagnoses, states an
One very closely associated topic is the debate
oversimplification of case conceptualizations and
about statistical vs. clinical significance. As an
omits relevant predictive variables and their
example, Nietzel et al. (1987) resumed in their
complex interaction, being associated with psycho-
meta-analytic study about the treatment of uni-
therapeutic process and outcome (Clarkin and
polar depression that “critical scholarship, clini-
Levy 2004). The extent of the problem of
cal acumen, and thoughtful debate” (p. 160)
simply classifying clients due to standard diagnos-
should be utilized to define criteria for clinical
tic classification systems becomes even more
significance in the respective research context.
apparent, facing the fact that definitions of diag-
This suggestion clearly deviates from classical
noses underlie changes due to regular revisions of
ways of dealing with outcome scores in an exclu-
the classification systems (WHO 1992; APA
sively statistical sense and the according calcu-
2000). Therefore, the focus on psychological pro-
lated differences. In this context, the establishment
cesses underlying the fulfillment of diagnostic
of a closer link between outcome and epidemio-
criteria was and is increasingly viewed to lead to
logical research is also being discussed (Russell
more significant findings (Persons 1986). Subse-
and Orlinsky 1996). The two most prominent
quently, rather psychological variables such as
approaches to measure clinical significance are
cognitive functions, emotional regulation, person-
the investigation (1) if clients show statistically
ality structure, and attachment history are dis-
reliable significant changes after treatment
cussed to interact relevantly with treatment than
(Jacobsen et al. 1999) and (2) if clients can be
the nosological diagnoses in the sense of the ICD
empirically distinguished from “normal” control
or DSM.
persons after treatment (Kendall et al. 1999).
54 D. Braakmann

3.2.4.4.2 Elaborated Quantitative Analytical the session they just completed. By focusing on
Methods immediate effects of important change processes,
Quantitative process approaches have increas- the HAT allows for considerable insight in the
ingly concentrated on characteristics within and texture of actual therapeutic change (Elliott
across session patterns. Examples for elaborated 2010).
analytical methods of quantitative process
research applied to respective data bases are, 3.2.4.4.4 The Task-Analytic Approach
for example, growth curve analysis (e.g., A major impulse that challenged the traditions of
Goldman and Anderson 2007; Sauer et al. 2003; the mainstream was the emergence of the task-
Tschacher and Ramseyer 2009), dynamic factor analytic approach (Rice and Greenberg 1984).
analyses, P-technique (Czogalik and Russell Rice and Greenberg (1984) criticized the main-
1995), and multivariate time series analyses stream approach of investigating groups of
(e.g., Feiler et al. 2005; Pole et al. 2002). The participants, which pre-assumed that they react
techniques have in common the consideration of in a homogenous way to a specific treatment
the development of variables over time. The because of their similarity in certain variables.
flourishing of these approaches finally focused Stressing the complexity of human experience
the refined longitudinal perspective which has and behavior as well as the richness of the thera-
to be taken if we want to deeply understand peutic process, they stated that this approach is
psychotherapy as a process that aims at changing not appropriate for gaining significant answers in
emotions, cognitions, and behavior over time psychotherapy research. Instead, they argued that
(Salvatore and Tschacher 2012). These kinds of change events within sessions have to be focused
quantitative process approaches help to over- and that observable markers of clients’ and
come the problem that cross-sectional data on therapists’ behavior must be identified to investi-
the process of psychotherapy disregard its tem- gate the process of change (Greenberg 1986).
poral dimension (Tschacher and Ramseyer Subsequently, groups of events should be investi-
2009). gated, indicating that a client is experiencing a
state or significant event at a specific point of
time, rather than groups of people (Goldman
3.2.4.4.3 The Qualitative Helpful Factor et al. 2010). Through this work, Rice and
Design Greenberg significantly influenced a paradigm
The intensification of qualitative research also shift in process-outcome research, assuming
influenced the kind of process-outcome research that groups of particular change events lead to a
being conducted. The qualitative helpful factor positive outcome.
design was developed as an increasingly popular
approach (Elliott 2010) that comprises two main 3.2.4.5 Cost-Effectiveness
alternative methods: (1) The application of a and Sociopolitical Pressure
qualitative change interview, asking the patients A generally heightened concern with cost-
at the end of therapy, or partway through, open- effectiveness and cost-benefit analyses reflects
ended questions that focus on what clients the growing sociopolitical pressure on psycho-
experienced as helpful, important, or hindering therapy research activities. Outcome of therapy
during the process, including delayed effects that has to be viewed as relative, and different per-
were not immediately apparent as well as to what spectives and evaluation criteria of success cause
they attribute changes that they have made dur- problems in research on psychotherapeutic out-
ing the psychotherapeutic process (Elliott come. Moreover, it is stressed that solely
et al. 2001); and (2) the application of the helpful professionals should be allowed to appraise thera-
aspects of therapy form (HAT, Llewelyn 1988), a peutic success. There is also a deficiency in
post-session questionnaire prompting clients to taking long-term results as well as on research
describe the most helpful or important aspect of of negative effects (e.g., Caspar 2009) so that,
3 Historical Paths in Psychotherapy Research 55

especially in this field, there are numerous and precise prognosis than comparable stable factors
concrete future tasks for the community. Cost- being measured at the beginning of therapy.
benefit analyses have to consider different aspects Among others, the very promising impulses might
of costs (e.g., direct, indirect, and intangible stem from the field of monitoring the patients’
costs), in case the economical effectivity—and outcome, such as by the consideration of recovery
therefore also its societal meaning – shall be curves (Lambert et al. 2001) and the associated
ascertained (e.g., Lamprecht 2006). Future treatment optimization, enhancement of treatment
designs in psychotherapy research have to face effects, and avoidance of negative effects.
these sociopolitical pressures and offer empirical Commensurate with technical media develop-
answers to respective questions. ments including the enormously quick increase
of the importance of the Internet in everyday life,
3.2.4.6 Major Developments studies also investigate process-outcome relation-
and Achievements ships in online psychotherapy (individual and
The fourth phase is especially characterized by group approaches) and, for example, e-mail fol-
an intensive deepening of process and process- low-up care of inpatient psychotherapeutic treat-
outcome research and by the emergence of qual- ment (Haug et al. 2008a, b).
itative and mixed-method approaches which lev-
eraged psychotherapy research not only in
justification but also in discovery. The Psycho- 3.3 The Birth and Development
therapeutic Process: A Research Handbook by of Common Factors
Greenberg and Pinsof (1986) stresses the signifi-
cance of this field of interest. Investigation and After common factors were introduced under
comparisons of successful and unsuccessful more general aspects above, the following part
cases (e.g., Detert et al. 2006; Hersoug 2010), of the chapter offers a more detailed view of
also with respect to client and therapist factors as contributions to the development of the concept
well as their interaction (e.g., Macdonald by significant persons as well as the shaping of
et al. 2007; Schindler et al. 1989; Wiseman and the construct during decades of research (see
Rice 1989), are utilized to depict and analyze the Chap. 11 and 15 for a discussion).
psychotherapeutic process, revealing that pro-
cess research is increasingly connected to out-
come variables, independent of whether it is 3.3.1 The Origin: Saul Rosenzweig
dealt with qualitative, quantitative, or mixed-
method approaches. The deepening of process It was Saul Rosenzweig (1907–2004), an Ameri-
and process-outcome research was accomplished can psychologist and therapist, who gave birth to
by increasingly focusing on dynamics on a the idea of common (pan-theoretical) factors in
microlevel (e.g., in-session level). Examples for psychotherapy, assigning more importance to
client-therapist interaction factors, which allow a them than to school-specific therapeutic elements
differentiation between successful and unsuc- (Rosenzweig 1936). Rosenzweig suggested
cessful cases, are mutual therapeutic engage- factors like catharsis, the “indefinable effect” of
ment, therapeutic negotiation, undirected client the personality of a good therapist, the “formal
reminiscence, and sustained therapist work consistency” of the therapeutic doctrine as a
(Czogalik and Russell 1995). Collectively, the basis for the clients’ psychological reintegration
most robust influence on therapeutic outcome, as a sign for their recovery, as well as the alter-
across single studies and meta-analyses, was native formulation of psychological events and
found for the working alliance, especially from the concept of interdependence of personality
the clients’ perspective (Orlinsky et al. 2004). organization. He hypothesized the named aspects
The concept of adaptive prognoses entails the to be potent, implicit therapeutic factors in psycho-
idea that process characteristics allow for more therapy that by that time had not been explicitly
56 D. Braakmann

formulated as curative factors. Moreover, he a disorder or problem that can be psychologically

argued that the coexisting success of different explained and be related to a specific mechanism
treatment approaches (as to theory and techniques) of change that corresponds to a theoretical expla-
means that the respective “therapeutic result is not nation of the problem. Hence, from this perspec-
a reliable guide to the validity of the theory” tive, particular therapeutic interventions should
(p. 412). Given the interdependence of personality be used that are viewed as the cause of the later
constituents, the particular (theoretical and tech- positive outcome of psychotherapy. The model is
nical) point from which change is approached called “medical,” because of its correspondence
should not be decisive for the therapeutic effect to the way of describing, explaining, and treating
(Rosenzweig 1936). The background of diseases in medicine, with the core characteristic
Rosenzweig’s work was a historical research on that a particular disease can be cured by means of
(also religious and supernatural) precursors of a particular substance or “ingredient.” In the
psychotherapy, resulting in his finding that they context of psychotherapy, this idea of particular
resemble each other with respect to ideas of effects of treatments is referred to as specificity
healing (interview with Saul Rosenzweig in (Wampold 2010). On the contrary, the contextual
October 2000, Duncan 2010). His creativity and model is the “derivative of the common factors
interest in literature led to the now-famous intro- view” (Wampold 2001, p. 20). It was originally
duction of the metaphor of the race announced by proposed by Jerome Frank (Frank and Frank
the dodo bird in Lewis Carroll’s Alice’s 1991) and stresses contextual factors of psycho-
Adventures in Wonderland (1865). By the use of therapy like the relationship with a helping per-
this metaphor, he aimed at depicting the state of son, the healing setting, and the conceptual
outcome research in psychotherapy. The race scheme or rationale that is provided as the
ended with the decision that “everybody has causal influences on clinical change. These can
won, and all must have prizes,” which from be considered as common characteristics of all
Rosenzweig’s point of view stated a perfect illus- psychotherapies that, following the contextual
tration of the equivalence of efficacy of different model, can be attributed to the majority of the
psychotherapeutic treatments. benefits of psychotherapy. Following Frank’s
A few years later, Heine (1953) referred to model, specific techniques and ingredients are
Rosenzweig and agreed to the idea that theo- necessary to create a treatment setting that is
retical approaches and specific interventions reliable and conclusive for the client, as well as
might be less important than, for example, the evoking hope, and at the same time a frame of
therapist. In addition, he argued that one single action that the therapist is convinced of (Frank
psychotherapy (an early idea of psychotherapy and Frank 1991).
integration) should be developed, instead of
keeping up and further developing various thera-
peutic schools. 3.3.3 The First Common Factor Model
and a Gap of References

3.3.2 The Medical Model vs. the The contextual idea of therapeutic change was
Contextual Model the basis of the very first conceptualization of a
common factor model by Rosenzweig (1936).
Two competing meta-models are referred to in Accordingly, several common factor models
the context of understanding and explaining the were formulated, one of them being Frank’s con-
nature of psychotherapy (Wampold 2001). The textual model (Frank 1961; Marmor 1962;
idea that treatments can achieve different Garfield 1995). Jerome Frank (1961) was the
punched-out effects is mainly based upon the first to publish a whole book on common factors
idea of a medical model of psychotherapy (e.g., across different forms of mental healing, includ-
Macklin 1973). This model assumes that there is ing psychotherapeutic treatment approaches. He
3 Historical Paths in Psychotherapy Research 57

was also a key person in the Johns Hopkins 3.3.4 The Very First Panel on
Psychotherapy Research Project. Based upon a Common Factors: Fitness of
conclusion of preceding comparative study of Interpretations vs. Correctness
psychotherapeutic approaches, it investigated
the common healing factors of psychotherapy In 1940, a very early panel on—among others—
(Frank 1992). ideas of common factors was organized by
In general, he added the idea of potential Goodwin Watson as part of a conference of the
effects of expectation and of placebo to the American Orthopsychiatric Society (Goldfried
existing conceptualization of the efficiency of and Newman 1992). The evolving Areas of
psychotherapy. He described a search for Agreement in Psychotherapy (Watson 1940)
similarities between different healing approaches was published, with one main conclusion being
and identified four features being an integral part the significance of the fitness of psychological
of all effective therapies: (a) an emotional con- interpretations (more than correctness) for a
fiding relationship, (b) a healing setting, (c) a specific client.
rationale that provides explanation and a curing Carl Rogers presented his ideas about working
procedure, and (d) rituals with active participa- with children, while Rosenzweig depicted his
tion of client and therapist (Frank 1973). concept of implicit factors. Although it remains
Unfortunately, the development of models unclear how much Rogers was influenced by
subsequent to Rosenzweig’s considerations and Rosenzweig’s thoughts on the qualities of a
conceptualizations entailed a gap of references to good therapist, Rogers no doubt kept referencing
Rosenzweig during the following decades which Rosenzweig and also invited him to speak to his
led to a misconception of the creatorship of the colleagues in Chicago in 1945 (Duncan 2010).
first common factor model as well as the dodo Although Carl Rogers is not even mentioned as a
bird metaphor. But both, the first model and the participant of the panel in 1940 in historical
metaphor, have to be clearly accentuated as material (interview transcript from 2000, Duncan
Rosenzweig’s brainchild in 1936 (Luborsky 2010), he referenced him in his book Counseling
et al. 1975; Duncan 2010). Being asked about and Psychotherapy, published in 1942, and kept
his reaction to this gap of reference, Rosenzweig stressing his impact in later publications.
himself reacted in a very composed way:
My passion lies in my current work. The joy is the
moment of discovery [. . .] And maybe, somewhere
down the line, someone will pick up on it—if they
3.3.5 Evidence for Common Factor
reference me fine, if not, that is the way it goes. I Models
doubt if I’ll notice when it is all said and done.
(quoted from interview transcript, Duncan 2010, The development of psychotherapy in many
p. 20)
countries has been very closely linked to and
And indeed a lot of “someones” picked it intertwined with medicine. From this perspec-
up. The core similarity of all common factor tive, specific psychological treatment ingredients
models is the significance of the collaborative have been argued to cause specific changes in
work of client and therapist to the disadvantage psychopathology. Following Wampold (2010),
of specific ingredients or interventions in “the status of superiority of treatment method,
psychotherapy. above all else, may well indeed be a consequence
of history rather of science” (p. 53).
58 D. Braakmann

On the basis of the current state of research, achieving the client’s goals in the given treat-
change in psychotherapy emerges from a core set ment frame. Especially the alliance formation in
of pan-theoretical factors that transcend different the initial stage (usually within the first three to
treatment approaches. An analysis by Wampold four sessions) of therapy decrees a positive pre-
(2001) reveals a difference of specific treatment dictive power (Horvath and Bedi 2002).
models accounting for just 1 % of the variance of
psychotherapeutic outcome. This result reveals 3.3.5.2 Therapist Factors
an even lower impact than in Lambert’s early There is a contradiction between the robustness
estimation of 15 % (Lambert 1992). of therapist factors as predictors for treatment
The current interpretation of common factors outcome and their disregard in research up to
and their contextual embedment was aptly recent times. Major findings support the delicate
worded by Hubble et al. (2010): “Accepting the idea that some therapists are more successful
premise that therapeutic factors constitute the than others. The recent state of evidence shows
engine of change, then monitoring and feedback that better therapists seem to make better use
offers the means to deliver them” (p. 40). (also of their knowledge) of the common factors
The statement summarizes the changes that to strive for good treatment outcomes (Hubble
recently took place in the common factor et al. 2010). Successful therapists seem to make
research field: the orientation toward the greater (and more skillful) contributions to the
contextualization of common factors. Although formation and maintenance of the therapeutic
there have not been major changes in the type of alliance, taking dynamic and interactional facets
common factors of interest, the context of the of their contribution into account. Hence, a major
factors as well as their interactional relationship part of the variability in therapists’ efficacy can
has been the main interest of recent approaches. be explained by differences in building and
Former studies estimated contributions of single maintaining the therapeutic bond (e.g., Baldwin
factors (e.g., Lambert 1992). Despite the aware- et al. 2007). This contains also significant
ness of this illegitimate oversimplification of the implications for training or research on training,
psychotherapeutic process, the first comprehen- because one important part could be improve-
sive reviews of studies implied the notion of ment of abilities to form alliances while taking
factors being invariant and proportionally fixed. a dynamic perspective.
Pie chart models were frequently used to illus-
trate estimated proportions (Hubble et al. 2010).
Instead of this linear idea of the effects of 3.3.5.3 The Rationale
common factors, recent approaches clearly view The rationale for the explanation of the client’s
therapy as a reciprocal process with the in- problems and the treatment, also called the
separable, interdependent, fluid, and dynamic “myth” by Frank and Frank (1991), states an
contributions of common factors over the thera- important common factor, in case it is convinc-
peutic course being the major catalyst of ingly communicated. It does not necessarily have
therapeutic outcome (Wampold 2010). The inter- to reflect “scientific truth,” but has to be accepted
dependent factors that are assigned major signifi- by the client to enfold its impact in psycho-
cance to can be grouped as follows. therapy by leading to adaptive responses (Imel
and Wampold 2008). This view is very similar to
3.3.5.1 Working Alliance the early descriptions of Rosenzweig (1936),
A positive alliance from the client’s perspective who stressed the importance of formal consis-
states one of the most powerful predictors of tency (compared to “correctness”). From today’s
therapeutic outcome (e.g., see Horvath point of view, his very early statements can be
et al. 2011 and Chap. 16). The alliance is per- viewed as crystal ball insight.
ceived in a positive way in the context of therapy Due to their little differential efficacy, tech-
if it offers a promising notion in direction of niques can be viewed as general healing factors.
3 Historical Paths in Psychotherapy Research 59

This means that they are not viewed as curative strategies and techniques from different thera-
in a specific sense, but generally powerful in peutic schools under the roof of a new conceptual-
setting up a consistent treatment setting, enhanc- ization of change, e.g., in the latter case from a
ing hope, expectations of change, and problem philosophical dialectic perspective. This has to be
resolution strategies in clients who have accepted differentiated from being merely eclectic in the
the rationale as a treatment basis. It has been sense that the treatment is based upon a whole
found that negative treatment outcome is related new theoretical building. Despite the proven
to a lack of focus and structure in the psychother- superiority of common factor impacts, in the
apeutic process (Lambert and Bergin 1994). area of very high symptom severity or severe
personality disorders, the limits of common
3.3.5.4 Client Factors factors are to a certain degree tested and
Hubble et al. (2010) stress that clients are the challenged. Therefore, especially for these aims,
most neglected impact factor in psychotherapy respective approaches and their refinement as well
research, including internal and external as their scrutiny for effectiveness are relevant also
resources. Strengths and resources as well as readi- for future developments and high quality of clini-
ness to change (McCarthy and Barber 2007), hope cal work and research.
(Hubble et al. 1999; Larsen and Stege 2010),
social support (Marziali 1987), and life events
(Pilkonis et al. 1984) have, among others, been 3.4 Future Perspectives
assigned significance as client characteristics.
Independent of the therapeutic approach, therapy With no doubt the further refinement of research
should therefore be specifically tailored to the methods is a topic of the history of psycho-
respective client’s needs and conditions. This therapy research but also of the future. Quanti-
idea is closely associated with the claim for the tative methods should be enhanced in order to
assessment of the quality, progress, and outcome enable researchers to take the contextuality and
of psychotherapy by clients. time dependency of change processes more into
account. The current intensive efforts to refine
qualitative process-outcome methodologies,
embracing the complexity of mechanisms of
3.3.6 Integrative Approaches change, are and will with no doubt be maintained
and intensified. This endeavor entails also the
The development of integrative approaches for further consideration of qualitative outcome
specific clinical problems can be viewed as a criteria. Mixed-method approaches have the
significant step, being closely associated with potential to unify the strengths of both quanti-
the movement of psychotherapy integration tative and qualitative and should as well be fos-
(Goldfried 2010, overview: Norcross and tered in the upcoming years. A desirable aim is
Goldfried 2005). Surprisingly, a very early not just to strengthen the three branches in a
ancestor can be traced back to the 1930s, when parallel independent way, but to strive for a per-
Thomas French was the first speaker in a meeting manent interaction between the three
of the American Psychiatric Association who approaches. This might impact the amelioration
promoted an integrative idea of psychothera- of especially common factor research in the
peutic approaches (French 1933). More recent future.
examples like cognitive analytic therapy (Rile Moreover, although much is said and written
1995), mindfulness-based cognitive therapy about intercultural issues and their relevance for
(Segal et al. 2002), or dialectic behavior therapy psychotherapy, the empirical basis for reasoning
for borderline personality disorder (Linehan in this field is comparatively thin. Various
1993) should be labeled “integrative” rather questions arise in this field, not only giving atten-
than eclectic, because they combine certain dance to the role of cultural characteristics as
60 D. Braakmann

potential relevant client variables but also as patients’ expression of hostility. J Consult Psychol
therapist variables and the fit of characteristics 24:1–8
Beck AT, Rush AJ, Shaw BF, Emery G (1979) Cognitive
in a therapeutic bond and their interaction. The therapy of depression. Guilford, New York
same is true for the interaction of client and Bergin AE (1963) The effects of psychotherapy: negative
therapist variables in general, and respective results revisited. J Couns Psychol 10:244–250
research questions will most probably be Bergin AE (1971) The evaluation of therapeutic
outcomes. In: Bergin AE, Garfield SL (eds) Handbook
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There is a strong need associated with socio- 1st edn. Wiley, New York, pp 217–270
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Bernheim H (1892) Hypnotisme, suggestion, psycho-
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