Louis G. Castonguay, J. Christopher Muran, Lynne E. Angus, Jeffrey A. Hayes, Nicholas Ladany, Timothy Anderson-Bringing Psychotherapy Research to Life_ Understanding Change Through the Work of Leading.pdf

Bringing
Psychotherapy
Research
to Life
Bringing
Psychotherapy
Research
to Life
Understanding Change
Through the Work of Leading
Clinical Researchers
Louis G. Castonguay,
Edited by
J. Christopher Muran, Lynne Angus,
Jeffrey A. Hayes, Nicholas Ladany,
and Timothy Anderson
American Psychological Association • Washington, DC

Copyright © 2010 by the American Psychological Association. All rights reserved. Except as
permitted under the United States Copyright Act of 1976, no part of this publication may
be reproduced or distributed in any form or by any means, including, but not limited to, the
process of scanning and digitization, or stored in a database or retrieval system, without the
prior written permission of the publisher.
Published by To order
American Psychological Association APA Order Department
750 First Street, NE P.O. Box 92984
Washington, DC 20002 Washington, DC 20090-2984
www.apa.org Tel: (800) 374-2721; Direct: (202) 336-5510
Fax: (202) 336-5502; TDD/TTY: (202) 336-6123
Online: www.apa.org/books/
E-mail: [email protected]
In the U.K., Europe, Africa, and the Middle East, copies may be ordered from
American Psychological Association
3 Henrietta Street
Covent Garden, London
WC2E 8LU England
Typeset in Goudy by Circle Graphics, Inc., Columbia, MD
Printer: United Book Press, Baltimore, MD

Cover Designer: Mercury Publishing Services, Rockville, MD
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Library of Congress Cataloging-in-Publication Data
Bringing psychotherapy research to life : understanding change through the work of leading
clinical researchers / edited by Louis G. Castonguay . . . [et al.].
p. cm.
ISBN-13: 978-1-4338-0774-9
ISBN-10: 1-4338-0774-2
1. Psychotherapy—Research—History. I. Castonguay, Louis Georges. II. American
RC337.B73 2010
616.89'14—dc22
2009046125
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America

First Edition
To the Society for Psychotherapy Research,
one of many generative and nurturing sources of psychotherapy
research, without which this book would not have been possible.
CONTENTS
Contributors .............................................................................................. xiii

Preface....................................................................................................... xvii
Chapter 1. A Brief Introduction to Psychotherapy Research ............ 3
J. Christopher Muran, Louis G. Castonguay,
and Bernhard Strauss
I. Establishing the Foundation for the Scientific Study

of Psychotherapy.................................................................................. 15
Chapter 2. Carl Rogers: Idealistic Pragmatist
and Psychotherapy Research Pioneer............................. 17
Robert Elliott and Barry A. Farber
Chapter 3. Jerome D. Frank: Psychotherapy Researcher
and Humanitarian .......................................................... 29
Bruce E. Wampold and Joel Weinberger
vii
Chapter 4. Lester Luborsky: A Trailblazer in Empirical
Research on Psychoanalytic Therapy............................. 39
Paul Crits-Christoph, Jacques P. Barber,
Brin F. S. Grenyer, and Louis Diguer
Chapter 5. Hans Strupp: A Founder’s Contributions to
a Scientific Basis for Psychotherapy Practice ................. 51
Karla Moras, Timothy Anderson,
and William E. Piper
Chapter 6. Aaron T. Beck: The Cognitive Revolution
in Theory and Therapy................................................... 63
Steven D. Hollon
II. Does Psychotherapy Work? .............................................................. 75

Chapter 7. Irene Elkin: “The Data Are Always Friendly” ............... 77
Karla Moras and M. Tracie Shea
Chapter 8. Kenneth I. Howard: The Best Friend
That Psychotherapy Research Ever Had........................ 89
David E. Orlinsky, Merton S. Krause,
Fredrick L. Newman, Robert J. Lueger,
and Wolfgang Lutz
Chapter 9. Allen E. Bergin: Consummate Scholar
and Charter Member of the Society
for Psychotherapy Research.......................................... 101
Michael J. Lambert, Alan S. Gurman,
and P. Scott Richards
Chapter 10. Klaus Grawe: On a Constant Quest for
a Truly Integrative and Research-Based
Psychotherapy............................................................... 113
Franz Caspar and Martin Grosse Holtforth
III. How Does Psychotherapy Work? ................................................. 125

A. Therapist Contributions ................................................................... 127
Chapter 11. Marvin R. Goldfried: Pioneering Spirit
and Integrative Force.................................................... 129
Louis G. Castonguay and John C. Norcross
viii CONTENTS
Chapter 12. Michael J. Lambert: Building Confidence
in Psychotherapy .......................................................... 141
Benjamin M. Ogles and Jeffrey A. Hayes
Chapter 13. Clara E. Hill: A Rebel With Several Causes................ 153
Sarah Knox
B. Client Contributions.......................................................................... 163

Chapter 14. Eugene Gendlin: Experiential Philosophy
and Psychotherapy........................................................ 165
David L. Rennie, Arthur C. Bohart,
and Alberta E. Pos
Chapter 15. Laura Rice: Natural Observer
of Psychotherapy Process ............................................... 175
Jeanne C. Watson and Hadas Wiseman
Chapter 16. Leslie Greenberg: Emotional Change Leads
to Positive Outcome..................................................... 185
Rhonda N. Goldman, Lynne Angus,
and Jeremy D. Safran
C. Relationship Variables ...................................................................... 197

Chapter 17. Edward S. Bordin: Innovative Thinker,
Influential Investigator, and Inspiring Teacher ........... 199
Michael J. Constantino, Nicholas Ladany,
and Thomas D. Borkovec
Chapter 18. Donald J. Kiesler: Interpersonal Manifesto .................. 211
Christopher C. Wagner and Jeremy D. Safran
Chapter 19. Lorna Smith Benjamin: Love, Loyalty,
and Learning in Close Attachment Relationships ...... 221
Kenneth L. Critchfield
Chapter 20. David E. Orlinsky: Developing Psychotherapy
Research, Researching Psychotherapist
Development ................................................................ 233
Michael Helge Ro/nnestad, Ulrike Willutzki,
and Margarita Tarragona
CONTENTS ix
D. Integration of Multiple Variables..................................................... 245
Chapter 21. Horst Kächele: Bringing Research, Practice,
and People Together .................................................... 247
Bernhard Strauss
Chapter 22. Enrico Jones: Appreciating Complexity ...................... 259
Tai Katzenstein, Peter Fonagy, and J. Stuart Ablon
Chapter 23. David A. Shapiro: Psychotherapeutic
Investigations ............................................................... 271
Michael Barkham, Glenys Parry,
and Gillian E. Hardy
Chapter 24. Robert Elliott: Commitment to Experience................. 283
Rhea Partyka
Chapter 25. William B. Stiles: Empathic Reflections,
Voices, and Theory Building........................................ 295
Meredith Glick Brinegar and Katerine Osatuke
IV. What Works for Whom?................................................................ 307

Chapter 26. Sol L. Garfield: A Pioneer in Bringing
Science to Clinical Psychology .................................... 309
Larry E. Beutler and Anne D. Simons
Chapter 27. Larry E. Beutler: A Matter of Principles....................... 319
Paulo P. P. Machado, Héctor Fernández-Álvarez,
and John F. Clarkin
Chapter 28. Sidney J. Blatt: Relatedness, Self-Definition,
and Mental Representation.......................................... 329
John S. Auerbach, Kenneth N. Levy,
and Carrie E. Schaffer
Chapter 29. William E. Piper: Negotiating the Complexities
of Psychotherapy .......................................................... 339
John S. Ogrodniczuk
x CONTENTS
V. Conclusion........................................................................................ 351
Chapter 30. Future Directions: Emerging Opportunities
and Challenges in Psychotherapy Research................. 353
Lynne Angus, Jeffrey A. Hayes, Timothy Anderson,
Nicholas Ladany, Louis G. Castonguay,
and J. Christopher Muran
Index ........................................................................................................ 363
About the Editors..................................................................................... 377
CONTENTS xi
CONTRIBUTORS
J. Stuart Ablon, Massachusetts General Hospital and Harvard Medical

School, Boston
Timothy Anderson, Ohio University, Athens
Lynne Angus, York University, Toronto, Ontario, Canada
John S. Auerbach, James H. Quillen Veterans Affairs Medical Center,
Mountain Home, TN, and East Tennessee State University, Johnson
City, TN
Jacques P. Barber, University of Pennsylvania, Philadelphia
Michael Barkham, University of Sheffield, Sheffield, United Kingdom
Larry E. Beutler, Palo Alto University, Palo Alto, CA
Arthur C. Bohart, Saybrook Graduate School, San Francisco, CA
Thomas D. Borkovec, Penn State University, University Park
Meredith Glick Brinegar, University of Illinois, Urbana–Champaign
Franz Caspar, Bern University, Bern, Switzerland
Louis G. Castonguay, Penn State University, University Park
John F. Clarkin, Weill Cornell Medical College, New York, NY
Michael J. Constantino, University of Massachusetts, Amherst
Kenneth L. Critchfield, University of Utah, Salt Lake City
xiii
Paul Crits-Christoph, University of Pennsylvania, Philadelphia
Louis Diguer, Laval University, Quebec City, Quebec, Canada
Robert Elliott, University of Strathclyde, Glasglow, United Kingdom
Barry A. Farber, Teachers College, Columbia University, New York, NY
Héctor Fernández-Álvarez, Fundación Aiglé, Buenos Aires, Argentina
Peter Fonagy, University College London, London, United Kingdom
Rhonda N. Goldman, Argosy University, Schaumburg, IL and the Family
Institute at Northwestern University, Evanston, IL
Brin F. S. Grenyer, University of Wollongong, Wollongong, Australia
Alan S. Gurman, University of Wisconsin School of Medicine and Public
Health, Madison
Gillian E. Hardy, University of Sheffield, Sheffield, United Kingdom
Jeffrey A. Hayes, Penn State University, University Park
Steven D. Hollon, Vanderbilt University, Nashville, TN
Martin Grosse Holtforth, University of Zürich, Zürich, Switzerland
Tai Katzenstein, Massachusetts General Hospital, Harvard Medical School,
Boston
Sarah Knox, Marquette University, Milwaukee, WI
Merton S. Krause, Northwestern University, Evanston, IL
Nicholas Ladany, Lehigh University, Bethlehem, PA
Michael J. Lambert, Brigham Young University, Provo, UT
Kenneth N. Levy, Penn State, University Park
Robert J. Lueger, Creighton University, Omaha, NE
Wolfgang Lutz, University of Trier, Trier, Germany
Paulo P. P. Machado, University of Minho, Braga, Portugal
Karla Moras, Merion Station, PA
J. Christopher Muran, Adelphi University and Beth Israel Medical Center,
New York, NY
Fredrick L. Newman, Florida International University, Miami
John C. Norcross, University of Scranton, Scranton, PA
Benjamin M. Ogles, Ohio University, Athens
John S. Ogrodniczuk, University of British Columbia, Vancouver, British
Columbia, Canada
David E. Orlinsky, University of Chicago, Chicago, IL
Katerine Osatuke, Veterans Health Administration National Center for
Organization Development, Cincinnati, OH
Glenys Parry, University of Sheffield, Sheffield, United Kingdom
Rhea Partyka, Cross Junction, VA
William E. Piper, University of British Columbia, Vancouver, British
Columbia, Canada
Alberta E. Pos, York University, Toronto, Ontario, Canada
David L. Rennie, York University, Toronto, Ontario, Canada
xiv CONTRIBUTORS
P. Scott Richards, Brigham Young University, Provo, UT
Michael Helge Rønnestad, University of Oslo, Oslo, Norway
Jeremy D. Safran, New School for Social Research, New York, NY
Carrie E. Schaffer, Charlottesville, VA
M. Tracie Shea, Veterans Affairs Medical Center and Brown University,
Providence, RI
Anne D. Simons, University of Oregon, Eugene
Bernhard Strauss, Institute of Psychosocial Medicine and Psychotherapy,
Jena, Germany
Margarita Tarragona, Universidad Iberoamericana, Mexico City, Mexico
Christopher C. Wagner, Virginia Commonwealth University, Richmond
Bruce E. Wampold, University of Wisconsin, Madison
Jeanne C. Watson, University of Toronto, Toronto, Ontario, Canada
Joel Weinberger, Adelphi University, Garden City, NY
Ulrike Willutzki, Ruhr-Univerität Bochum, Bochum, Germany
Hadas Wiseman, University of Haifa, Haifa, Israel
CONTRIBUTORS xv
PREFACE
In describing how one of their early collaborations began, David

Orlinsky and Ken Howard1 wrote that “some good things start over soup”
(p. 477). In the early 1960s, the founders of the Society for Psychotherapy
Research (SPR) did in fact develop the Therapy Session Report (a comprehen-
sive measure of psychotherapy process) while meeting for light dinners at an
old hotel in Chicago. The idea for the present book also emerged around din-
ner. It was 40 years later, the soup had been replaced by steak frites, and we
suspect that much more wine was involved—we were, after all, in a French
bistro! This dinner took place at the 2005 SPR meeting in Montreal, and while
we joyfully exchanged funny stories and laughed a lot (wine will make you do
that), there was also a wave of sadness over part of the evening (wine will also
make that happen). Although the six of us fervently discussed many exciting
findings of psychotherapy research, we also talked about the fact that SPR
was at an important point in its history. A number of its leaders (including
Howard) had recently died, and the health of many other luminaries in our
1Orlinsky, D. E., & Howard, K.I. (1986). The psychological interior of psychotherapy: Explorations with
the therapy session reports. In L. S. Greenberg & W. M. Pinsof (Eds), The psychotherapeutic process:
A research handbook (pp. 477–501). New York, NY: Guilford Press.
xvii
field was deteriorating. In addition to the impact that this had on a personal
level (all of us had interacted with and/or been mentored by some of these leg-
endary figures), we were also saddened by the strong possibility that the contri-
butions of these and other influential researchers, whose work served as the
foundation of our own, may not be known by young scholars or by psychother-
apy researchers primarily active in organizations other than SPR. Particularly
worrisome for the six of us was the thought that many clinicians might not be
aware of clinical implications of the research that giants of our field had con-
ducted for the last 50 years—a painful reminder of the tenuous connection
between practice and science.
There is no doubt that a gap exists between what researchers write
about and what practitioners do in therapy. Clinicians do not find much
guidance for their practice in the empirical literature. This, however, does
not mean that clinicians are not interested in research. What they are not
interested in are studies (including investigations that they may have con-
ducted themselves as part of their master’s and/or dissertation theses) that
fail to be clinically relevant or meaningful. Our experience in working col-
laboratively with clinicians, in the context of training graduate students,
conducting studies in practice research networks, and practicing psychother-
apy ourselves, is that clinicians are thirsty for empirical knowledge that can
help them better understand the complexity of therapy and improve the
impact of their own interventions. Although they may not be avid readers
of original empirical papers, clinicians (both novice and experienced) are
very eager to attend talks or workshops by “well-known” researchers whose
significant contributions to psychotherapy research and practice have been
made via peer-reviewed journals. Yet clinicians are rarely motivated to
seek these findings through methodologically detailed research reports found
in these scientific journals or even dry summaries of these research reports.
They would rather seek out the “big picture” of findings from a full career of
scientific labor. Why?
While clinicians are eager to learn what researchers have to say about
psychotherapy, they tend not to be particularly enthralled with the mechanism
by which most researchers choose to communicate their understanding.
Although the methodological and statistical sections in journal articles are cru-
cial for evaluating the scientific validity of the findings they report, they most
often overshadow the clinical implications of these findings. From a purely clin-
ical standpoint, the papers published in these journals frequently fail to deliver
substantive and detailed practical guidelines. One would be hard-pressed to
learn how to practice psychotherapy by relying primarily on such a prestigious
periodical as the Journal of Consulting and Clinical Psychology—even though not
publishing in this type of journal can be the kiss of death for the career of many
professional psychologists in academia.
xviii PREFACE
Yet clinicians seek out iconic psychotherapy researchers first and fore-
most because they are interested in research. These researchers often have a
central and clear message about research—one that readily can be applied
to the practice of psychotherapy. Many clinicians want to hear what
researchers have found about what types of patients benefit from therapy,
how relationship problems can best be handled, under which circumstances
emotions can be deepened, how to foster insight, and/or how to facilitate
behavioral activation—just to name a few clinically relevant issues. Thera-
pists want to learn about the major findings of leading researchers and the
lessons one can derive from years of empirical investigations—fully know-
ing that elsewhere they can find the methodological and statistical proce-
dures used in the investigations. They also want to know what led these
researchers to investigate particular aspects of psychotherapy, how their find-
ings have been influenced by (and have impacted) their respective clinical
practice and teaching, and how their research programs reflect some mile-
stones of their careers. When it comes to research, many clinicians want to
hear scientifically rich and clinically relevant messages that are embedded
in meaningful stories.
This book brings together a large number of influential research pro-
grams that have changed the way we think about and practice psychother-
apy. It presents the main findings derived by such scholarly and empirical
endeavors in a way that, we hope, is conceptually meaningful and clinically
relevant. These findings are also described in the context of the personal and
professional journeys within which they originated; they are, in other words,
historicized to some extent. We believe that such conceptualizing of scien-
tific work can bring research to life and, in doing so, may help many clinicians
to get back in touch with the excitement toward science that many of us felt
as we first entered graduate school.
The marriage between research and practice has been long recognized
as a troubled one. There are clinicians who reject research, and there are
researchers who refuse to practice. There are, however, researchers who prac-
tice, and there are certainly practitioners who conduct research. This volume
presents the contributions of those who are the embodiment of the scientist–
practitioner model and depict this marriage at its best.
The volume describes findings that will resonate with many clinicians’
observations and reflections. In addition, it presents empirical results that will
challenge some therapists’ habitual ways of thinking about clients and their
work with them. We hope that, ultimately, it will provide new directions to
improve practice. This attempt of ours to make empirical findings clinically
relevant, and thus to reduce the gap between research and practice, is one of
the two overarching goals of this book. The other goal is to pay tribute to
pioneers in the field of psychotherapy research.
PREFACE xix
A number of outstanding individuals have transformed the modern
field of psychotherapy, and we believe that the time is ripe for a book that
would provide a brief summary of the research contributions of at least some
of them. Clearly, this book could not cover all of the major contributors to
psychotherapy research in the last 50 years. Specifically, it focuses on the
legacies of several leading researchers who have been associated with the
foundation and early growth of SPR—via their direct involvement in the
society, the importance of their research program, and/or the generative
value (in terms of shaping current research trends or methods) of their work.
The editors recognize that, as current and past members of the executive
council of the North American chapter of SPR, the selection of the
researchers celebrated in this book reflects regional bias. We hope, however,
that our consultation with colleagues within and outside of North America
has attenuated this bias.
We are also aware that the research programs highlighted in this book
are predominantly anchored in psychodynamic and humanistic traditions.
While this reflects the roots of SPR, it fails to do justice to the major contri-
butions that leaders of other orientations (especially cognitive–behavioral)
have made to psychotherapy research, let alone to the influence that these
researchers have had on the research of many SPR members. In an attempt
to capture such contributions, as well as to pay tribute to their own theo-
retical allegiance, the first two editors of this book (L. G. Castonguay and
J. C. Muran) are currently working on a companion book to celebrate and
bring to life the research of prominent figures in the cognitive–behavioral
therapy tradition. Dividing psychotherapy researchers across two books may
still be viewed by some as reflecting, if not perpetuating, arbitrary barriers
between theoretical allegiances. This, however, is not our intention, and we
hope that the combination of the two books will, eventually, allow for broad
coverage of clinical researchers who have played an important role in under-
standing and developing psychotherapy, irrespective of the concepts they
have focused on and the research methods they have favored.
The task of selecting the researchers to be featured in this book, even
when restricting ourselves to individuals who have contributed to or substan-
tially influenced the development of SPR, was an arduous one, both intellec-
tually and emotionally. As for any book, we were allowed a limited number of
pages. Within those limits, we also wanted to devote sufficient space for each
chapter to capture the major contributions of recognized scholars, the clinical
implications of their empirical accomplishments, and the developmental and
personal contexts within which their work has evolved. Thus, we had very dif-
ficult choices to make. We spent long conference calls brainstorming and
weighing possible options. We also devoted many hours going over leading
xx PREFACE
textbooks, handbooks, and published reviews of empirical literature to compile
list after list of possible “candidates.” We also consulted with several senior col-
leagues who provided us with suggestions that were very helpful in guiding our
selection process. In the end, though, we had to make painful decisions about
whom not to feature. Several well-known SPR contributors, including some of
our own mentors, did not make the final list despite our profound respect for
the quality and heuristic value of their work. We will have to live with the
choices we made and hope that those not selected, at least for this first edition
of the book, will understand the difficulty of our task.
We also carefully chose the authors for each of the chapters, who in
return provided truly remarkable, eloquent, and inspiring tributes to the work
and legacy of the researchers they were asked to write about. We primarily
chose authors based on their relationships, as mentees or close colleagues,
with the featured researchers (after consulting with each of them, whenever
possible). We also chose authors based on their own contributions to the field.
The majority of these authors are reputed psychotherapy researchers from all
over the world, and many of them will, we hope, have their own work recog-
nized in future editions of this book.
The preparation of this book has been facilitated by the help of many indi-
viduals. In particular, we want to express our gratitude to Susan Reynolds
(senior acquisitions editor at APA Books), not only for her trust and support
but also for her crucial help in creating the outline that guided each of the chap-
ters in this volume. We are also thankful to many friends and colleagues who
provided us with advice and suggestions regarding the general structure of the
book, as well as the selection of featured researchers and selected authors. These
include Jacques Barber, Larry Beutler, Franz Caspar, John Clarkin, Paul Crits-
Christoph, Irene Elkin, Marvin Goldfried, Martin Grosse Holtforth, Paulo
Machado, Erhard Mergenthaler, John Norcross, David Orlinsky, Glenys Parry,
David Rennie, and Bernhard Strauss. We are also grateful to many of the fea-
tured researchers and chapter authors who provided us with much needed
encouragement and support during the completion of our task. Such warmth
has been experienced by us as a reflection of the sense of connection that is
prevalent in SPR.
We hope that this book will further contribute to this spirit of affilia-
tion and collaboration by celebrating the work and impact of some of its
leaders and by encouraging the integration of research and practice. We also
hope that it will foster stronger connections between different generations
of researchers. One of our goals was to raise the awareness of new scholars
about the sources of some of the current themes and methods of research
while highlighting some future research directions they can take in advanc-
ing psychotherapy. In the current stage of our careers, we see ourselves, like
PREFACE xxi
so many of our peers and colleagues in SPR, as part of a cohort that should
facilitate the advancement of our field by creating links between newer and
older generations of psychotherapy researchers. With this role in mind, we
would like to dedicate this book to our mentors, who have shown us the
way, and to our students, who have not only helped us in our quests but
have and will continue to contribute to the growth of SPR and psychother-
apy research.
xxii PREFACE
Bringing
Psychotherapy
Research
to Life
1
A BRIEF INTRODUCTION TO
PSYCHOTHERAPY RESEARCH
J. CHRISTOPHER MURAN, LOUIS G. CASTONGUAY,
AND BERNHARD STRAUSS
Like many histories, the story of psychotherapy research is one repeatedly

marked by creative advances, inherent tensions, and paradigm shifts. As one
of the first, Freud (1916/1963) himself struggled with the question of how best
to study psychotherapy: On the one hand, he promoted the case study method
to demonstrate evidential support for his new psychological treatment; on the
other hand, he criticized the use of statistical procedures to understand complex
clinical processes and to make comparisons among them (see Strupp & Howard,
1992). Freud’s struggle is one not too different from what continues today for
contemporary psychotherapists and researchers. To understand this struggle, it
is important to recognize that “every scientific method rests upon philosophical
presuppositions” (May, 1958, p. 8) and that for the most part Western science
(psychology included) has been shaped by two major traditions (Allport, 1955).
AN INTELLECTUAL–CULTURAL VIEW OF THE FIELD
American and British psychology has been dominated by the empirical

or realist tradition, with its origins traced to Newton and developed in
Lockean/Humean thought. It is a tradition marked by various analytic
3
methods, including operationism and pragmatism, and most notably by logi-
cal positivism with its emphasis on confirmation based on objective data and
quantitative or statistical analysis. In contrast, Continental European psychol-
ogy has been more pluralistic, though largely dominated by the rationalist or
idealist tradition, with its origins in Cartesian principles and developed in
Leibnizian/Kantian thought. From this tradition, methods such as phenome-
nology, hermeneutics, and structuralism emerged that privilege the subjec-
tive and interpretive and promote exploratory and qualitative approaches to
research, such as case studies.
There has been a long-standing tension between these two traditions that
can be boiled down to the fundamental epistemological question How do
we know? From the empirical perspective, our knowledge is a posteriori, depen-
dent on sense experience. The mind is seen as tabula rasa and as essentially pas-
sive in nature. From the rationalist perspective, our knowledge can be intuited
or deduced from intuitions and thus exists a priori to sense experience. In this
regard, the mind is seen as having a potentially active core of its own. The
empirical sees knowledge as socially derived, the rationalist as individually
driven. There have been many challenges to these views in the past few decades
collectively described as postmodern, which suggest a more complex and criti-
cal perspective, a more both/and sensibility, and a more skeptical approach to
knowing (see Muran, 2001a).
Despite this tension, the empirical tradition has mostly dominated scien-
tific method in psychotherapy research, probably because of to the extensive
role that North American and British researchers have played in the field. This
dominance can also be attributed to socioeconomic factors regarding evidence-
based practice and cost containment in Western health care, as well as an over-
all cultural shift toward the values of instrumentality, efficiency, and conformity
(Cushman & Gilford, 2000). There have been challenges to this dominance,
however, especially in the form of attempts to blend the two perspectives (e.g.,
attempts to quantify subjective states and to develop both exploratory and
confirmatory models, as well as challenges to their authority altogether: that
is, attempts to promote methodological plurality and contextual analyses;
see Muran, 2001b, 2002).
A BRIEF HISTORY OF THE FIELD
There have been a number of histories written about psychotherapy

research (e.g., Lambert, Bergin, & Garfield, 2004; Orlinsky & Russell, 1994;
Strupp & Howard, 1992). Most trace the origins back to the 1920s, when sev-
eral psychoanalytic institutes first addressed the basic question Does treatment
4 MURAN, CASTONGUAY, AND STRAUSS

work? by logging outcomes and reporting impressive improvement rates (see
Otto Fenichel’s 1930 report from the Berlin Institute, Ernest Jones’s 1936
report from the London Institute, and Franz Alexander’s 1937 report from the
Chicago Institute)—a practice that was effectively discontinued by analytic
institutes following World War II. The behavioral tradition also began in the
early 1920s to assess treatment response (e.g., Jones, 1924). From the very
beginning, the question How best to measure change? was a great challenge.
The Third Force, the humanistic tradition, entered the psychotherapy
research fray in the 1940s, when Carl Rogers began a research program, first
at Ohio State University and then at the University of Chicago. In addition
to conducting controlled outcome studies of client-centered therapy, he pio-
neered the use of recorded sessions, which marked the beginning of process
research. He also experimented with novel measurement strategies and multi-
variate statistical procedures. Perhaps most significant, he mentored an
impressive list of psychotherapy researchers (including Allen Bergin, Sidney
Blatt, Irene Elkin, Eugene Gendlin, Donald Kiesler, Laura Rice, Reinhard
Tausch, and Charles Truax) who went on to become quite innovative and
influential with regard to the study of psychotherapy process. In the 1950s,
Rogers and his group moved to the Department of Psychiatry at the Univer-
sity of Wisconsin to study the treatment of the more severely disturbed. He
also published one of the first books devoted to the topic of psychotherapy
research, as well as a seminal article about the role of relationship factors that
has had a long-lasting impact on process-outcome research (see Chapter 2,
this volume).
Subsequent to the start of Rogers’s research program, two other early
programs of note were established. In the context of developing his clinic,
Karl Menninger attracted a number of talented investigators, including Robert
Wallerstein, Otto Kernberg, Robert Holt, and Lester Luborsky, who made
significant contributions to a naturalistic 30-year longitudinal study of
the psychoanalytic treatment of 42 patients that began in the mid-1950s (see
Wallerstein, 1986). Around the same time, Jerome Frank and colleagues (see
Chapter 3, this volume) initiated a program in the Phipps Clinic at Johns
Hopkins University. They designed a series of studies of 54 patients (includ-
ing 20-year follow-up evaluations) aimed at understanding the common heal-
ing factors of psychotherapy, rather than focusing on the effect of a specific
treatment approach.
In 1952, Hans Eysenck published a review of the psychotherapy out-
come literature that would become a major impetus to the field. He reviewed
24 studies and concluded that there was no evidence demonstrating that
psychotherapy works (i.e., that psychotherapy produces no more changes
than what would be expected by spontaneous remission) and that psycho-
analysis even was less effective than no treatment. This critique resulted in a
A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 5

number of rejoinders that criticized Eysenck’s analysis and provided further
reviews (e.g., Bergin, 1971; Lubosky, Singer, & Luborsky, 1975), which cul-
minated in the emergence and application of meta-analytic statistical tech-
niques that subjected reviews to more systematic quantitative analysis. The
first example of this, conducted by Smith, Glass, and Miller (1980) on
475 studies, demonstrated that psychotherapy was superior to no treatment
and placebo controls (these authors also concluded that different psychother-
apies seemed to have equal effects across a variety of disorders, which became
an important influence to the psychotherapy integration movement and the
study of common factors in psychotherapy; see Chapter 11, this volume).
The late 1950s and early 1960s marked the beginning of incredible
growth in the field of psychotherapy research. There was a proliferation of
psychotherapy research programs: Lester Luborsky established the Penn
Psychotherapy Research Project, and Hans Strupp launched his Vanderbilt
Studies—both efforts to study their respective time-limited dynamic therapies;
Bruce Sloane and colleagues (Sloane, Staples, Cristol, Yorkston, & Whipple,
1975) conducted the first controlled clinical trial comparing behavior therapy,
dynamic psychotherapy, and a waiting-list control as part of the Temple Psy-
chotherapy Project. Other noteworthy programs included Edward Bordin’s at
the University of Michigan, William Snyder’s at Penn State University, David
Orlinsky and Kenneth Howard’s Chicago/Northwestern Project, Mardi
Horowitz’s Langley Porter Projects, David Malan’s at Tavistock, David
Barlow’s Center for Stress and Anxiety Disorders (State University of New
York–Albany/Boston University), Harold Sampson and Joseph Weiss’s Mount
Zion Psychotherapy Research Group, David Shapiro’s at Sheffield University,
and Arnold Winston’s Beth Israel Psychotherapy Research Program.
There were also important developments with regard to the organi-
zational structure of the field: First, there were three American Psycholog-
ical Association (APA) conferences on psychotherapy research—in 1958
(Washington, DC: Rubinstein & Parloff, 1959), 1961 (Chapel Hill: Strupp
& Luborsky, 1962), and 1966 (Chicago: Shlien, Hunt, Matarazzo, & Savage,
1968). Subsequent to these conferences, Kenneth Howard and David
Orlinsky concluded that the field had grown to the point that there was a need
for a new organization and took preliminary steps to develop it, which cul-
minated in the first meeting of the Society for Psychotherapy Research held
in Chicago in 1970. Around the same time, several behaviorists, including
Joseph Cautela, Cyril Franks, Arnold Lazarus, Andrew Salter, and Joseph
Wolpe, founded the Association for the Advancement of Behavior Therapy
(AABT; now the Association for Behavioral and Cognitive Therapies), which
held its first meeting in Washington, DC, in 1967. The establishment of
AABT marked a distinct increase in interest in behavior therapy and the study
of its efficacy (see DiLoreto, 1971; and Paul, 1967, as seminal studies). The

only downside to the development of two separate communities with overlap-
ping interests was the unfortunate splitting of the field that is still felt today.
Second, the field was further organized by new journal and book publi-
cations. In 1963, Psychotherapy: Theory, Research, and Practice was established,
soon to be followed by several new journals focusing on behavior therapy—
for example, the Journal of Applied Behavioral Analysis in 1968 and Behavior
Therapy and the Journal of Behavior Therapy and Experimental Psychiatry in
1970. (Other notable journals that were established much later on and had
great influence on the field include Cognitive Therapy and Research in 1980
and Psychotherapy Research in 1992.) Of course, the APA journals Journal of
Consulting Psychology (1937, which later became the Journal of Consulting and
Clinical Psychology) and Journal of Counseling Psychology (1954), the American
Psychiatric Association’s American Journal of Psychiatry (1844) and the Amer-
ican Medical Association’s Archives of General Psychiatry (1919) were impor-
tant outlets for psychotherapy research.
Various book projects also played an organizing role. Arguably the most
important was Allen Bergin and Sol Garfield’s Handbook of Psychotherapy
and Behavior Change, which is now in its fifth edition (most recently edited
by Michael Lambert; see Chapters 9, 12, and 26, this volume). Other note-
worthy books that provided substantive reviews of the research literature in
psychotherapy included J. Meltzoff and M. Kornreich’s Research on Psycho-
therapy (1970), and Alan Gurman and Andrew Razin’s Effective Psychother-
apy (1977). Two other landmark books described instruments then available
to conduct empirical investigation: Donald Kiesler’s The Process of Psycho-
therapy: Empirical Foundations and Systems of Analysis (see Chapter 18), and
Irene Elkin Waskow and Morris Parloff ’s Psychotherapy Change Measures
(1975). These books set the foundation for further innovative instruments
and psychotherapy research programs, with several of them later captured
by Leslie Greenberg and William Pinsof ’s The Psychotherapeutic Process: A
Research Handbook (1986) and Larry Beutler and Marjorie Crago’s Psycho-
therapy Research (1991): For example, Enrico Jones’s Berkeley Psychother-
apy Research group, Leonard Horowitz’s Stanford University Collaborative
project, Clara Hill’s and Bill Stiles’s respective verbal response systems,
William Pinsof ’s Family Therapist Coding System, and Adam Horvath and
Leslie Greenberg’s Working Alliance Inventory. The influence of these early
methodological contributions can also been seen in newer empirical programs
that have continued to expand our understanding of therapeutic change (see
Chapter 11, this volume).
Finally, the National Institute of Mental Health (NIMH) exerted a great
deal of influence on shaping the field of psychotherapy research, and the late
1960s saw significant developments at NIMH that laid the groundwork for this
influence to increase. NIMH had provided funding for the mentioned APA

conferences on psychotherapy research. By 1966, it established the Clinical
Research Branch, within which the Psychotherapy and Behavioral Interven-
tion section had responsibility for grants and contracts concerned with psycho-
therapy research. By 1980, this section was elevated to branch status as the
Psychosocial Treatments Research Branch, with Morris Parloff as its first
chief. Although NIMH has since gone through several reorganizations,
which resulted in the integration of this branch into a new structure, its
development did set the stage for the NIMH Treatment of Depression Col-
laborative Research Program (TDCRP)—a multisite controlled clinical
trial initiated in the late 1970s by Morris Parloff and Irene Elkin. The
TDCRP compared the relative efficacy of two psychotherapies (cognitive
behavioral therapy and interpersonal psychotherapy) and a pharmacological
intervention (imipramine) with a placebo + support condition (see Chap-
ter 7, this volume). It was a state-of-the-art randomized clinical trial that
included treatment manuals and adherence checks and that became the stan-
dard by which other outcome studies were subsequently judged and developed.
Many of the clinical trials that followed provided the bases for what came
to be known as the empirically supported treatment (EST) movement (Chambless
& Ollendick, 2001). Consistent with the epistemological assumptions underly-
ing their approach to therapy, a large number of cognitive–behavioral-oriented
researchers have contributed to the EST movement (e.g., Stewart Agras, Nathan
Azrin, Aaron Beck, David Barlow, Edward Blanchard, Thomas Borkovec, Kelly
Brownell, David Clark, Edward Craighead, Gerald Davison, Robert DeRubeis,
Paul Emmelkamp, Christopher Fairburn, Edna Foa, Steven Hayes, Richard
Heimberg, Steven Hollon, Neil Jacobson, Robin Jarret, Alan Kazdin, Terence
Keane, Philip Kendall, Peter Lewinsohn, Marsha Linehan, Isaac Markus, Alan
Marlatt, Daniel O’Leary, Gerald Patterson, Stanley Rachman, Paul Savolsky,
Linda Sobell, Terence Wilson). Although researchers from the other orienta-
tions have conducted outcome studies providing empirical support to their
approaches (e.g., see Chapter 16, this volume), to a great extent these com-
munities, namely, the analytic and humanistic, have not fully embraced and
participated in the development of EST (see Safran & Aron, 2001).
The 1970s marked a critical intellectual turn or paradigm shift in psy-
chotherapy research as investigators moved toward more intensive analyses
and methodological pluralism in their study of psychotherapy. Gordon Paul’s
(1967) and Donald Kiesler’s (Chapter 18, this volume) respective calls for
greater specificity, for multidimensional analysis of “what treatment, by whom,
is most effective for this individual with that specific problem, and under
which set of circumstances” (Paul, 1967, p. 111) spurred researchers to inves-
tigate, over several decades, how therapeutic interventions could be matched
with clients’ characteristics (see Chapters 10, 27, 28, and 29, this volume).
Perhaps as a result of the postmodern milieu that was taking hold of our intel-

lectual culture, there was an increased emphasis on intensively studying the
psychotherapy process, including relationally oriented and contextually sen-
sitive investigations. Among those analytically and humanistically oriented,
this took the form of studying the patient–therapist interaction (e.g., see
Chapters 4, 17, and 19, this volume). These efforts paved the way for the estab-
lishment of empirically supported therapeutic relationships (Norcross, 2002),
which countered the EST movement and included the study of such variables
as the working alliance (Horvath & Bedi, 2002), alliance rupture and repair
(Safran & Muran, 1996), empathy (Bohart et al., 2002), positive regard
(Farber & Lane, 2002), and countertransference reactions (Gelso & Hayes,
2002). Among behaviorists, the increased emphasis on intensive analyses
involved the refinement and application of single-case experimental designs
(e.g., Kazdin, 1978). This inspired the development of case formulation meth-
ods in all the traditions as well (e.g., Eells, 2008).
This intellectual turn also led to a number of methodological innovations
that expanded the horizons of psychotherapy research. These included the
quantification of subjectivity, that is, the use of subjective ratings of the patient
and therapist, which was a rebellion against positivism and its emphasis on the
exclusive study of overt behavior (e.g., Strupp, Horowitz, & Lambert, 1997). In
addition, these innovations involved the use of complex statistical analyses to
measure change, including Howard and colleagues’ (see Chapter 8, this vol-
ume) dose–effect and outcome phase model, patient-focused research, and
expected treatment response, as well as Lambert’s (see Chapter 12) research
on assessment and reduction of non-responders, therapist effect (e.g., Wampold,
2001), and interaction between technical and relational variables (Barber
et al., 2006; Crits-Christoph et al., 1988). In addition, it manifested in
increased interest in discovery-oriented, exploratory, qualitative, and narrative-
based methods (e.g., Mowrer, 1988; Toukmanian & Rennie, 1992; see also
Chapters 13, 24, and 25, this volume). Especially noteworthy examples of this
were the introduction of the task analytic method to psychotherapy research
by Laura Rice and Leslie Greenberg (see Chapters 15 and 16, this volume) and
programmatic linguistic analyses of psychotherapy narratives that have been
conducted by Wilma Bucci and Horst Kächele and the Ulm research group
(including Erhard Mergenthaler). Involving a sophisticated blend of qualita-
tive and quantitative methodologies, these programs demonstrate the feasibil-
ity and fruitfulness of integrating epistemological traditions (Castonguay, 1993)
that, as we mentioned at the beginning of this chapter, are at the roots of psy-
chotherapy research. Taken together, these methodological and statistical
innovations are likely to help researchersbetter understand how clients, thera-
pists, and a host of process variables are involved in patterns of interaction and
interdependence that lead to or interfere with therapeutic change (Castonguay
& Beutler, 2006).

OUR PURPOSE AND RATIONALE
With this chapter, we have provided a brief narrative history of psycho-

therapy research, including some background on the intellectual and cultural
currents of the times, as well as a summary of the major developments and con-
tributions of the important figures in the field. Our objective was to set the stage
for the next chapters of this book, in which psychotherapy research is brought
to life through a series of biographical sketches. In other words, consistent
with a postmodern sensibility (e.g., Cushman, 1995; Miller, 1991), this book
aims to make psychotherapy research more accessible to clinicians and other
researchers by personalizing and contextualizing the significant findings in the
lives of the major figures who found them.
REFERENCES
Alexander, F. (1937). Five year report of the Chicago Institute for Psychoanalysis,
1932–1937.
Allport, G. W. (1955). Becoming: Basic considerations for a psychology of personality.
New Haven, CT: Yale University Press.
Barber, J. P., Gallop, R., Crits-Christoph, P., Frank, A., Thase, M. E., Weiss, R. D., &
Connolly Gibbons, M. B. (2006). The role of therapist adherence, therapist com-
petence, and the alliance in predicting outcome of individual drug counseling:
Results from the NIDA Collaborative Cocaine Treatment Study. Psychotherapy
Research, 16, 229–240. doi:10.1080/10503300500288951
Bergin, A. E. (1971). The evaluation of therapeutic outcomes. In A. E. Bergin &
S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 217–270).
New York, NY: Wiley.
Beutler, L. E., & Crago, M. (Eds.). (1991). Psychotherapy research: An international
review of programmatic research. Washington, DC: American Psychological
Association. doi:10.1037/10092-000
Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy. In J. C.
Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and
responsiveness to patients (pp. 89–108). New York, NY: Oxford University Press.
Castonguay, L. G. (1993). “Common factors” and “nonspecific variables”: Clarification
of the two concepts and recommendations for research. Journal of Psychotherapy
Integration, 3, 267–286.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work.
New York, NY: Oxford University Press.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological
interventions: Controversies and evidence. Annual Review of Psychology, 52,
685–716. doi:10.1146/annurev.psych.52.1.685

Crits-Christoph, P., Cooper, A., & Luborsky, L. (1988). The accuracy of therapist’s
interpretations and the outcome of dynamic psychotherapy. Journal of Consult-
ing and Clinical Psychology, 56, 490–495. doi:10.1037/0022-006X.56.4.490
Cushman, P. (1995). Constructing the self, constructing America: A cultural history of
psychotherapy. Reading, MA: Addison-Wesley.
Cushman, P., & Gilford, P. (2000). Will managed care change our way of being?
American Psychologist, 55, 985–996. doi:10.1037/0003-066X.55.9.985
DiLoreto, A. O. (1971). Comparative psychotherapy. New York, NY: Aldine-Atherton.
Eells, T., ed. (2008). Handbook of Psychotherapy Case Formulation, 2nd ed. New York,
NY: Guilford Press.
Eysenck H J. (1952). The effects of psychotherapy: an evaluation. Journal of Consult-
ing and Clinical Psychology, 16, 319–324.
Farber, B. A., & Lane, J. S. (2002). Positive regard. In J. C. Norcross (Ed.), Psycho-
therapy relationships that work: Therapist contributions and responsiveness to patients
(pp. 175–194). New York, NY: Oxford University Press.
Fenichel. O. (1930). Ten years of the Berlin Psychoanalytic Institute, 1920–1930.
Freud, S. (1916/1963). Analytic therapy. In J. Strachey (Ed.), Standard edition of the
complete works of Sigmund Freud (Vol. 16, pp. 448–463). London, England:
Hogarth Press.
Gelso, C. J., & Hayes, J. A. (2002). The management of countertransference. In
J. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions
and responsiveness to patients (pp. 267–283). New York, NY: Oxford Univer-
sity Press.
Greenberg, L. S., & Pinsof, W. (1986). The psychotherapeutic process: A research hand-
book. New York, NY: Guilford Press.
Gurman, A. S., & Razin, A. M. (Eds.). (1977). Effective psychotherapy: A handbook of
research. New York, NY: Pergamon.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psycho-
Jones, E. (1936). Report of the clinic work (London Clinic of Psychoanalysis): 1926–1936.
Jones, M. C. (1924). A laboratory study of fear: The case of Peter. Pedagogical Semi-
nary, 31, 308–316.
Kazdin, A. E. (1978). Methodological and interpretative problems of single-case
experimental designs. Journal of Consulting and Clinical Psychology, 46, 629–642.
doi:10.1037/0022-006X.46.4.629
Lambert, M. J., Bergin, A. E., & Garfield, S. L. (2004). Introduction and historical
overview. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy
and behavior change (5th ed., pp. 3–15). New York, NY: Wiley.
Lambert, M. J. (Ed.). (2004). Bergin and Garfield’s handbook of psychotherapy and
behavior change (5th ed.). New York, NY: Wiley.

Mahrer, A. R. (1988). Discovery-oriented psychotherapy research: Rationale, aims, and
methods. American Psychologist, 43, 694–702. doi:10.1037/0003-066X.43.9.694
May, R. (1958). The origins and significance of the existential movement in psychol-
ogy. In R. May, E. Angel, H. F. Ellenberger, & F. Henri (Eds.), Existence: A new
dimension in psychiatry and psychology (pp. 3–36). New York, NY: Basic Books.
doi:10.1037/11321-001
McNeilly, C. I., & Howard, K. I. (1991). The effects of psychotherapy: A reevalu-
ation based on dosage. Psychotherapy Research, 1, 74–78. doi:10.1080/10503
309112331334081
Meltzoff, J., & Kornreich, M. (1970). Research in psychotherapy. New York, NY:
Atherton.
Miller, N. K. (1991). Getting personal: Feminist occasions and other autobiographical acts.
New York, NY: Routledge.
Muran, J. C. (2001a). Contemporary constructs and contexts. In J. C. Muran (Ed.),
Self-relations in the psychotherapy process (pp. 3–44).Washington, DC: American
Psychological Association. doi:10.1037/10391-001
Muran, J. C. (2001b). Meditations on Both/And. In J. C. Muran (Ed.), Self-relations
in the psychotherapy process (pp. 347–372). Washington, DC: American Psycho-
logical Association. doi:10.1037/10391-000
Muran, J. C. (2002). A relational approach to understanding change: Plurality and
contextualism in a psychotherapy research program. Psychotherapy Research, 12,
113–138. doi:10.1080/713664276
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapists contri-
butions and responsiveness to patients. New York, NY: Oxford University Press.
Orlinsky, D. E., & Russell, R. L. (1994). Tradition and change in psychotherapy
research: Notes on the fourth generation. In R. L. Russell (Ed.), Reassessing psy-
chotherapy research (pp. 185–214). New York, NY: Guilford Press.
Paul, G. L. (1967). Outcome research in psychotherapy. Journal of Consulting Psychol-
ogy, 31, 109–118. doi:10.1037/h0024436
Rubinstein, E. A., & Parloff, M. B. (1959). Research in psychotherapy. Washington,
DC: American Psychological Association. doi:10.1037/10036-000
Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic
alliance. Journal of Consulting and Clinical Psychology, 64, 447–458.
Shlien, J. M., Hunt, H. F., Matarazzo, J. D., & Savage, C. (Eds.). (1968). Research in
psychotherapy, Vol. 3. Washington, DC: American Psychological Association.
Sloan, R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., & Whipple, K. (1975).
Psychotherapy vs. behavior therapy. Cambridge, MA: Harvard University Press.
Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Balti-
more, MD: Johns Hopkins University Press.
Strupp, H. H., & Howard, K. I. (1992). A brief history of psychotherapy research. In
D. K. Freedheim, H. J. Freudenberger, J. W. Kessler, S. B. Messer, D. R. Peterson,

Strupp, H. H., & P. L. Wachtel (Eds.), History of psychotherapy: A century of
change (pp. 309–334). Washington, DC: American Psychological Association.
Strupp, H. H., & Luborsky, L. (Eds.). (1962). Research in psychotherapy (Vol. II).
Washington, DC: American Psychological Association.
Strupp, H. H., Horowitz, L. M., & Lambert, M. J. (Eds.). (1997). Measuring patient
changes in mood, anxiety, and personality disorders. Washington, DC: American
Psychological Association. doi:10.1037/10232-000
Toukmanian, S. G., & Rennie, D. L. (1992). Psychotherapy process research: Paradig-
matic and narrative approaches. Thousand Oaks, CA: Sage Publications.
Wallerstein, R. S. (1986). Forty-two lives in treatment: A study of psychoanalysis and
psychotherapy. New York, NY: Guilford Press.
Wampold, B. E. (2001). The great psychotherapy debate: Model, methods, and findings.
Mahwah, NJ: Erlbaum.
Waskow, I. E., & Parloff, M. B. (1975). Psychotherapy change measures. Washington,
DC: Department of Health, Education, and Welfare.

I
ESTABLISHING THE
FOUNDATION FOR
THE SCIENTIFIC STUDY
OF PSYCHOTHERAPY
2
CARL ROGERS: IDEALISTIC
PRAGMATIST AND PSYCHOTHERAPY
RESEARCH PIONEER
ROBERT ELLIOTT AND BARRY A. FARBER
In many ways, Carl Rogers was and continues to be a figure of contra-

dictions. He was a dreamy idealist who was also a hard-headed pragmatist;
a humanist grounded in positivism; a shy, somewhat stiff Midwesterner
who ended up advocating openness, disclosure, and intimacy; a persuasive
advocate for empathic and respectful listening raised in a judgmental, non-
expressive home; the founder of a major school of therapy who discouraged
followers, training institutes, and professional organizations; an academic
who rebelled against almost all of the trappings of academia; and a key figure
in the origins and development of psychotherapy research who at a crucial
moment gave it all up to move to California to pursue encounter groups, edu-
cational reform, and peace-making. What are we to make of these contradic-
tions? Do they detract from his contributions? Or are they essential to what
drove him and what continues to inspire his supporters more than 20 years
after his death in 1987?
Rogers’s contributions to both practice and research are extensive.
His filmed interview with Gloria (Shostrom, 1965) is almost certainly the
most widely viewed clinical training recording ever made. His clinical career
included work with adults and children, small and large groups, and even war-
ring political entities. He wrote prolifically and compellingly about applying
17
client-centered (later person-centered) approaches to problems related to
education, marriage, racism, and geopolitical disputes. More generally, his
emphasis on the mutative aspects of the relationship per se has been accepted
by virtually all contemporary schools of psychotherapy, including those aligned
with cognitive behavior therapy and psychodynamically-oriented approaches
(Farber, 2007).
MAJOR CONTRIBUTIONS
Often obscured by the importance and far-reaching effects of his clini-

cal innovations are Rogers’s seminal contributions to psychotherapy research.
Arguably, he was the first major psychotherapeutic figure who insisted on test-
ing the validity of his clinical ideas. He was committed to making his clini-
cal material available to all interested parties so that others could analyze and
evaluate the process and outcome of his work. His 1942 book, Counseling and
Psychotherapy, contains the first fully transcribed psychotherapy case ever
published, “The Case of Herbert Bryan.” He was proud of his research pro-
gram and understood its significance for changing the field:
These phonographic accounts, and the typescripts which have been
made from them, have exposed the processes of counseling and therapy
to an objective and microscopic examination which has illuminated the
principles and problems of counseling in significant ways which thus far
have only been partially utilized. This procedure holds much promise for
the future.” (Rogers, 1942, p. ix)
Rogers was not the first to conduct psychotherapy research. Crude out-
come studies, most consisting of simple tallies of therapist-perceived improve-
ment of heterogeneous samples of patients, can be traced back to the 1920s
and 1930s (Bergin, 1971). What Rogers and his colleagues did was to change
dramatically the methods and focus of psychotherapy research. In the course
of his career, Rogers pioneered or foreshadowed most of the major genres of
psychotherapy research: process research; systematic, controlled outcome
research; process-outcome research; and finally, surprisingly, qualitative
research. For example, while retaining an interest in outcome, Rogers began
to examine the process of psychotherapy. His awareness that the words and
actions of the therapist as well as the patient contribute substantially to the
effectiveness of therapy was well ahead of its time. He traced client thematic
patterns across sessions, looking for changes in clients’ sense of self (e.g., greater
congruence between their perceptions of real and ideal selves) and also look-
ing for what we would now call “ruptures in the therapeutic alliance.” He also
investigated the ingredients underlying therapists’ effectiveness, famously
18 ELLIOTT AND FARBER

hypothesizing that therapists’ provision of genuineness, positive regard, and
empathy—in conjunction with the client’s ability to experience, to at least a
minimum degree, these last two attitudes—were the necessary and sufficient
conditions for client change (Rogers, 1957). This work set the stage for the
field’s current emphasis on the overarching importance of the therapeutic
alliance in facilitating positive outcome. Rogers was also the first major psy-
chotherapeutic figure to analyze a “failure” case (Rogers & Dymond, 1954),
expecting to learn as much from dissecting what went wrong as from analyz-
ing the details of what, in other circumstances, had gone right. More gener-
ally, Rogers recognized the complexity of the therapeutic process and the
need to investigate empirically the many variables involved. He asked, “What
happens? What goes on during a period of contacts? What does the counselor
do? The client?” (Rogers, 1942, p. 30). He was aware that research—what he
termed “experimental study” (Rogers, 1942, p. 240)—should serve as a guide
to answer clinical questions.
It is also noteworthy that as early as 1942 Rogers was advocating for the
inclusion of research methods courses within professional training programs.
A counselor, he wrote, should have “adequate techniques for evaluating his
own work and that of others, and thus a sound basis for progress” (Rogers,
1942, p. 257). The radical nature of Rogers’s position is apparent in the con-
trast with Freud’s oft-quoted response in the 1930s to a researcher’s attempts
to investigate the concept of repression: “I have examined your experimen-
tal studies for the verification of the psychoanalytic assertions with interest.
I cannot put much value on these confirmations because the wealth of reli-
able observations on which these assertions rest make them independent of
experimental verification” (cited by MacKinnon & Dukes, 1962). Moreover,
his research contributions to the field were so extensive and influential that
in 1984 the Society of Psychotherapy Research (SPR) awarded him (along
with Lester Luborsky) an SPR Senior Career Award.
EARLY BEGINNINGS
Kirschenbaum’s (2007) biography of Rogers provides more information

than ever before about Rogers’s life and allows us to comprehend the full
impact of Rogers’s extensive accomplishments. Much of what follows is
drawn from this account.
Carl Rogers was born in 1902, the fourth of six children, in a suburb of
Chicago. Both his father, a successful businessman and college graduate, and
his mother were Christian fundamentalists, subscribing to the virtues of a close
family, hard work, and piety (i.e., no alcohol, dancing, theater attendance,
or even card games). As a boy, Rogers was seen—and even teased—by his
CARL ROGERS 19
family as a reserved and oversensitive child who often retreated to the
comfort of his books.
Motivated by his father’s wish to pursue farming as a side interest (which
soon grew into an early agribusiness venture), and by both parents’ wish to pro-
tect their children from the temptations of living near a big city, the family
moved to a farm outside Chicago when Carl was 12. There, Rogers developed
a great interest in moths, rearing caterpillars and watching their development.
Moreover, encouraged by his father, Rogers studied scientific agriculture,
becoming familiar with experimental methods that emphasized the need for
hypothesis testing, control groups, and random assignment.
Given these influences, it is not surprising that, at the University of
Wisconsin, Rogers first turned his attention to scientific agriculture, and then
to the ministry. Shortly after graduation, he married a young woman he
had known since childhood, Helen, and the two of them moved to New York,
where Carl began his studies at Union Theological Seminary. He soon
became disenchanted with the doctrinaire nature of religious training, and
during his second year of studies he began taking courses in psychology at
Teachers College, Columbia University. Soon, he became a full-time student
there, studying clinical and educational psychology in an academic culture
marked by fairly strict adherence to research, statistics, and measurement. For
his doctoral dissertation he developed a test for measuring adjustment in
young adolescents.
ACCOMPLISHMENTS
Following graduation, Rogers accepted a position with the Child

Study Department of the Rochester (New York) Society for the Prevention
of Cruelty to Children. During his 12 years in Rochester, he carried out a
search for an approach that made sense to him and could be proven effec-
tive. However, in this search he found himself severely hampered by two
gaps in the existing literature: the absence of verbatim records of therapy
and the lack of research on different therapeutic approaches. These limita-
tions compelled him to spend most of these years experimenting with dif-
ferent approaches to therapy. His search was documented in his first book,
The Clinical Treatment of the Problem Child (Rogers, 1939), in which he
argued that the conduct of psychotherapy needed to be grounded in the
principles of scientific inquiry so that it could be measured and objectified.
This book, with its critique of directive approaches to child therapy, also
contains the seeds of the nondirective approach, which he adapted prima-
rily from the work of the psychoanalyst Otto Rank (considered by some a
maverick) and the social worker Jessie Taft.

Therapy Process Research
Rogers’s academic career began at Ohio State University in 1939, where

he developed his formative ideas about client-centered therapy. These ideas
culminated in his book Counseling and Psychotherapy (1942). In 1940, he had
been able to obtain phonographic recording equipment and had begun record-
ing therapy sessions. (A complex process: two phonographs were required so
that while one was ending its few minutes of recording, the other would
begin.) This led to several further developments. First, he and his students
developed client consent procedures for recording and methods for tran-
scribing sessions. Next, they began figuring out what to do with these data,
in the process inventing therapy process research. As a first step, they classi-
fied the different types of therapist responses (e.g., questions, giving informa-
tion, persuading, interpreting), in some studies (e.g., Porter, 1941) categorizing
each therapist response as “directive” or “nondirective.” Under Rogers’s
supervision, Snyder (1945) carried out the first sequential process research
paradigm study in which client and therapist responses were both rated
to identify which therapist responses led to which client responses; for
example, Snyder found that asking questions and making interpretations
did not lead to client insight, whereas simple acceptance and clarification
of feelings did.
Systematic, Controlled Outcome Research
In 1945, Rogers moved to the University of Chicago to establish a

counseling center there. The Chicago Counseling Center became a home
for the development and expansion of client-centered therapy, and a place
where research was strongly encouraged. He obtained his greatest scien-
tific and professional recognition during this period: In 1947, he became
the president of the American Psychological Association (APA). In 1951,
Client-Centered Therapy was published; in 1954, a book of research studies,
Psychotherapy and Personality Change (coedited by Rosalind Dymond) came
out; and in 1956, Rogers received the Distinguished Scientific Contribu-
tion Award from APA.
Rogers’s move to the University of Chicago also led to the development
of the genre of large, systematic, controlled therapy research. At this time, he
began moving away from his earlier interest in therapist technique, toward
a more attitudinal–relational view that made outcome research more appeal-
ing. At first, Rogers and his students contented themselves with simple
pre–post studies to document the nature and extent of client change over
the course of therapy. These studies used then-standard psychological measures,
such as the Thematic Apperception Test (TAT) and the Rorschach, with
CARL ROGERS 21
small samples of clients and no experimental controls. However, they sub-
sequently obtained a series of grants for a larger study, the first large (N = 25)
controlled investigation of psychotherapy outcome. This study used two dif-
ferent nonrandom no-treatment controls (Rogers & Dymond, 1954): One
was a silent control group of nontreatment-seeking individuals matched to
the treatment sample (a design that would be used 20 years later by Strupp
and colleagues for the first Vanderbilt Psychotherapy Project); the other was
a waiting-list control group of clients whose therapy was delayed for 2 months.
While this study was later criticized for failing to randomize clients to treat-
ment (less distressed clients were assigned to the waiting-list condition), it
was an important step forward in the development of what is today consid-
ered the definitive group design for treatment research, the randomized
clinical trial.
Measures for Person-Centered/Experiential Therapies
A key element of systematic psychotherapy research is the use of theory-

relevant measures of outcome and process. Where these do not exist, as is
so often the case, they must be invented. Thus, to support their increasingly
sophisticated outcome studies and to assess the validity of their emerging
theory, Rogers and his colleagues found that they needed measures for key
client-centered concepts, such as congruence/incongruence, therapist facil-
itative attitudes, and client level of process or experiencing. (Actually, mea-
sure development is a consistent theme in Rogers’s scientific career, from
his dissertation to the early therapy process measures to the Chicago and
Wisconsin studies.)
Among the first of these instruments to be developed to support the
Chicago Counseling Center research was the Butler-Haig Q-Sort measure
of self-concept congruence/incongruence, which measured discrepancies
in ratings of actual and ideal self, with reduction in discrepancy seen as an
indicator of positive change (Rogers & Dymond, 1954). After this came
measures of therapist facilitative attitudes, including the Barrett-Lennard
Relationship Inventory (Barrett-Lennard, 1962), a client and therapist
self-report measure of accurate empathy, congruence, warmth and non-
possessiveness, and the most widely used measure of the therapeutic rela-
tionship prior to the advent of therapeutic alliance measures in the 1980s.
Then, after Rogers and part of his team moved to Wisconsin to carry out
the Schizophrenia Project, work began on developing observational pro-
cess measures of therapist facilitative conditions and client experiencing
(Rogers, Gendlin, Kiesler, & Truax, 1967), instruments that became the
paradigmatic therapy process measures for a generation of psychotherapy
research.

Process–Outcome Research
In 1957, Rogers decided returned to his alma mater, the University of

Wisconsin, a decision largely influenced by his desire to broaden the impact
of his ideas by training psychiatrists along with psychologists. His new Wis-
consin research group employed their new observational measures in an ambi-
tious study applying client-centered therapy in the treatment of schizophrenia
(Rogers et al, 1967). These measures were necessary for establishing another
new genre of research that Rogers and his team invented: the process–outcome
paradigm, in which key therapy processes are sampled from therapy sessions
and used to predict posttherapy outcome.
To be effective, process–outcome research needs to be guided by an
explicit, detailed theoretical formulation. This was supplied by Rogers’s
classic 1957 paper, “The Necessary and Sufficient Conditions for Change in
Therapeutic Personality Change,” which launched hundreds of psychotherapy
studies (see Orlinsky, Ronnestad, & Willutski, 2004). In this article, Rogers
made the radical and somewhat outrageous claim that therapist warmth, empa-
thy, and genuineness account completely for client posttherapy change. More-
over, he went beyond bold prediction to propose ways in which the key
variables could be measured and the hypothesis tested.
Today, the Wisconsin Project is regarded as a noble failure: Its results
were ambiguous and failed to support many of the key hypotheses; in addi-
tion, the study has passed into psychotherapy research folklore for the level
of interpersonal conflict among team members, which featured threatened
lawsuits and delayed its publication for years, so that the study was seen as
outdated by the time it was finally published (see Kirschenbaum, 2007, for
some of the juicy details). Nevertheless, this study influenced the field indi-
rectly via the measures developed for it and through its clear implementation
of the process–outcome research paradigm.
Qualitative Inklings
Rogers’s major success during his years at Wisconsin was not in the
research realm but rather with an immensely popular book, On Becoming a
Person (1961). He had never been particularly at home in academia—among
other grievances, he detested academic politics and power struggles—and
had long harbored deep-seated doubts about conventional understandings of
human nature and science. It appears likely that his experiences in Wiscon-
sin permanently soured him on both academia and quantitative psychother-
apy research (Kirschenbaum, 2007). He left full-time university life in 1963
to become a member of a new, nonprofit institution, the Western Behavioral
Sciences Institute (La Jolla, California), dedicated to humanistically oriented
CARL ROGERS 23
research in the field of human relations. His final organizational home was in
another newly created institution, the Center for Studies of the Person, formed
in 1968. During his years in California, he published a number of popular
books, including those that focused on encounter groups, education, politics,
and marriage. His last years were devoted primarily to issues of international
and group relations, and world peace.
Beginning in 1966 at Western Behavioral Sciences Institute, however,
Rogers began a search for alternatives to traditional positivist approaches to
studying people, hosting a series of dialogues among leading philosophers
(Kirschenbaum & Henderson, 1989). By the mid-1980s, shortly before his
death, he had aligned himself instead with more experience-based and inter-
personal approaches to study and understanding, preferring to think in terms
of research partners or coresearchers. He was interested in the kind of infor-
mation that could be gleaned from mutual understanding, an undertaking not
unlike that emphasized by contemporary relationally oriented psychoanalytic
thinkers as well as qualitative methodologists.
These efforts are almost totally unknown today, but they contain within
them the unmistakable first stirrings of the antipositivist revolution in the
social sciences that emerged in the 1980s and eventually gave rise in the
1990s to modern qualitative research methods. As Kirschenbaum (2007)
noted, the most likely explanation for the obscurity of this final research con-
tribution by Rogers is that he was unable to provide a specific alternative to
traditional quantitative research methods. Rogers’s strength had always been
his ability to link ideals to practice via concrete examples. However, in the
mid-1960s there was nothing concrete yet to draw on, and it was not until
shortly before his death in 1987 that the field caught up enough with Carl
Rogers for him to be able to point to specific nonpositivist methods. Never-
theless, it is our view that Rogers’s final contribution to psychotherapy research
lies precisely in his having helped create the initial conditions that, 25 years
later, led to the rapid emergence and dissemination of qualitative psychother-
apy research (e.g., Rennie, Phillips, & Quartaro, 1988), like the legendary
butterfly of chaos theory flapping its wings in Asia.
CONCLUSION
We have tried to make the case for Carl Rogers’s having founded or pio-
neered nearly all the major genres of psychotherapy research, including, indi-
rectly, qualitative research. At first, he did this through his own personal
efforts, but increasingly over the years his influence was mediated through the
students and colleagues he mentored and encouraged. Some of these, like
Gene Gendlin, Laura Rice, and Natalie Rogers, his daughter, went on to

develop their own unique person-centered forms of individual therapy and
theory, while others became important as psychotherapy researchers in their
own right, including (to name just a few) Marjorie Klein, Donald Kiesler,
Allen Bergin, Irene Elkin, Godfrey Barrett-Lennard, Germain Lietaer, and
(again) Laura Rice. An outstanding example is Irene Elkin, whose role in the
design and conduct of the National Institute of Mental Health Collaborative
Study of Treatments of Depression shows the unmistakable influence of the
Chicago and Wisconsin studies. Others who did not work directly with Rogers
but were nevertheless inspired by his work included William Miller (founder
of motivational interviewing). Still others, too many to even try to list, became
his intellectual grandchildren by virtue of having been mentored by former
students of Rogers (e.g., Michael Lambert, Les Greenberg, Robert Elliott).
For humanistically oriented psychotherapy researchers, Rogers’s depar-
ture from academia is today regarded as (to quote Don McLean) “the day the
music died”; that is, the beginning of the long decline in the person-centered/
experiential/humanistic therapy tradition, leading to its near eclipse in the
1980s and eventually to recent hard-fought attempts to revive its standing
through reinvigorated theory, research, and practice. For 20 years, a predom-
inant view (e.g., Lietaer, 1990) has been that it all went wrong when Rogers,
disillusioned with the intransigence of his academic colleagues at the Uni-
versity of Wisconsin, frustrated with the infighting of his research team, and
longing for new challenges, left for more convivial company and climate in
San Diego. Without research and significant new theory development, the
person-centered approach (as it now came to be called) lost respectability and
began to be pushed out of academia and mental health practice. If only Rogers
had stayed in academia and continued to encourage research, the complaint
goes, the approach would have fared much better over the ensuing decades,
and we wouldn’t have such an uphill battle today.
This narrative has a certain amount of credibility: Clearly, when we, as
psychologists, compare the impact of Rogers’s original evidence-based work
on individual therapy to his later nonresearch-based applications of person-
centered principles to small and large groups, education, couple relationships,
multicultural communication, intergroup conflict and peace-making, it does
appear to us that the earlier work has had a greater impact. However, sev-
eral arguments can be made to counter this claim: First, important research
on person-centered therapy continued in Europe through the supposed dry
period. Second, although the main line of Rogerian thought as it applies
to individual therapy appears to have gone into stasis in the mid-1960s,
Rogers’s departure encouraged important theoretical offshoots to develop
in the 1970sand 1980s, including focusing and process–experiential therapy
(Kirschenbaum, 2007). Third, the “dark ages” narrative reflects the rather
narrow view of the traditional mental health professions and academics, who
CARL ROGERS 25
never fully embraced Rogers’s iconoclastic views. Fourth, although the person-
centered school of therapy appears to have gone into decline, at least in North
America, it is also quite clear that during Rogers’s last 20 years, his ideas about
the important role of the therapeutic relationship in effective psychotherapy
were absorbed into all the major approaches, suggesting “infusion” as a better
metaphor than “decline” (Farber, 2007).
Today, the person-centered and experiential approaches are enjoying a
lively revival and are expanding their applicability; moreover, research on
these newer client-centered models, especially on humanistic–experiential
therapies, is proliferating (e.g., Elliott et al., 2004). The central contradiction
between idealism and pragmatism that drove Rogers has been assimilated by
his intellectual progeny as a creative tension that continues to inspire con-
temporary theory, research, and practice on humanistic and related therapies.
Rogers’s legacy, as a pioneer in both the clinical and research realms, lives on.
REFERENCES
Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in

therapeutic change. Psychological Monographs, 75 (43, Whole No. 562).
S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change: An empir-
ical analysis (pp. 217–270). New York, NY: Wiley.
Elliott, R., Greenberg, L. S., & Lietaer, G. (2004). Research on Experiential Psycho-
therapies. In M. J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy and
behavior change (5th ed., pp. 493–539). New York, NY: Wiley.
Farber, B. A. (2007). On the enduring and substantial influence of Rogers’ not-quite
necessary nor sufficient conditions. Psychotherapy: Theory, Research, Practice,
Training, 44. 289–294.
Kirschenbaum, H. (2007). The life and work of Carl Rogers. Ross-on-Wye, England:
PCCS Books.
Kirschenbaum, H., & Henderson, V. L. (Eds.). (1989). Carl Rogers: Dialogues. Boston,
MA: Houghton Mifflin.
Lietaer, G. (1990). The client-centered approach after the Wisconsin Project: A per-
sonal view on its evolution. In G. Lietaer, J. Rombauts, & R. Van Balen (Eds.),
Client-centered and experiential psychotherapy in the nineties (pp.19–45). Leuven,
Belgium: Leuven University Press.
MacKinnon, D., & Dukes, W. F. (1962). Repression. In L. Postman (Ed.), Psychol-
ogy in the making (pp. 662–744). New York, NY: Knopf.
Orlinsky, D. E., Rønnestad, M. H., & Willutski, U. (2004). Fifty years of psychother-
apy process and outcome research: Continuity and change. In M. Lambert (Ed.),
Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.,
pp. 307–389). New York, NY: Wiley.

Porter, E. H. (1941). The development and evaluation of a measure of counseling inter-
view procedures. Columbus: Ohio State University (Unpublished thesis).
Rennie, D. L., Phillips, J. R., & Quartaro, G. K. (1988). Grounded theory: A prom-
ising approach to conceptualization in psychology? Canadian Psychology, 29,
139–150. doi:10.1037/h0079765
Rogers, C. R. (1939). The clinical treatment of the problem child. Boston, MA:
Houghton Mifflin.
Rogers, C. R. (1942). Counseling and psychotherapy. Boston, MA: Houghton Mifflin.
Rogers, C. R. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic person-
ality change. Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357
Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin.
Rogers, C. R., & Dymond, R. F. (Eds.). (1954). Psychotherapy and personality change:
Coordinated research studies in the client-centered approach. Chicago, IL: Univer-
sity of Chicago Press.
Rogers, C. R., Gendlin, E. T., Kiesler, D. J., & Truax, C. B. (Eds.). (1967). The ther-
apeutic relationship and its impact: A study of psychotherapy with schizophrenics.
Madison, WI: University of Wisconsin Press.
Shostrom, E. L. (Producer) (1965). Three approaches to psychotherapy (Part 1) [Film].
Orange, CA: Psychological Films.
Snyder, W. U. (1945). An investigation of the nature of nondirective psychother-
apy. Journal of Genetic Psychology, 33, 193–223.
CARL ROGERS 27
3
JEROME D. FRANK: PSYCHOTHERAPY
RESEARCHER AND HUMANITARIAN
BRUCE E. WAMPOLD AND JOEL WEINBERGER
The professional contributions of Jerome D. Frank, PhD, MD, or “Jerry,”

as he was known to family and friends, exemplify two major themes. First,
Frank was committed to using evidence to reveal the essence of phenomena
and abhorred dogmatism. Second, he was dedicated to improving society and
establishing peace in a troubled world. These two strands led to significant
contributions to the understanding of psychotherapy, the focus of this volume,
but also to a psychological understanding of national leaders in a nuclear age.
EARLY BEGINNINGS
Frank was born in 1909 in New York City. He died in Baltimore at age
95, living through a period that spanned two world wars and two post–world
war Asian conflicts (Korea and Vietnam), the industrialization of the West-
ern world, and the spawning of globalization in the context of computers and
technology. He earned his bachelor’s degree at Harvard College in 1930, dur-
ing which time he became acquainted with the work of Kurt Lewin. He
worked with Lewin in Berlin (1930–1931) before earning his PhD at Harvard
in 1934 and while a postdoc at Cornell. The experience in Berlin with Lewin
29
was important intellectually and socially. Throughout his career, Frank sub-
scribed to Lewin’s thesis that cognition, behavior, and emotion are largely
determined by the current social environment. This piqued Frank’s interest
in motivation. Lewin’s emphasis on “action research,” which suggested that
the best way to understand a phenomenon was to attempt to change it, fueled
Frank’s interest in psychotherapy (Frank, 1992). As well, Frank was present
in Germany when the Nazi party won its first significant election; Lewin’s
belief that psychologists should be involved in social issues elicited Frank’s
interest in promoting social justice, which had been nurtured by the Frank
family’s involvement in the ethical culture movement (Julia Frank, personal
communication, Oct. 5, 2007). He was soon involved in political issues in
Berlin (American Psychological Association, 1986).
Having completed his doctorate in psychology, Frank satisfied what was
for some time a latent desire to be a physician by enrolling in the Harvard
Medical School, where he received his MD in 1939. He began psychiatry res-
idency at Johns Hopkins after completing an internship at New York Hospi-
tal. Immediately after residency, he spent several years in the United States
armed forces. He was serving in the Far East when the two atomic bombs were
detonated in Japan.
MAJOR ACCOMPLISHMENTS
Frank contributed to the field of psychology in two major areas: (a) the
psychological issues of nuclear weapons and war and (b) the process and out-
comes of psychotherapy. Although the focus of this volume is on the latter,
it would be remiss to ignore his contributions to the former, which clearly
intertwined with his perspectives on psychotherapy.
Psychological Issues of Nuclear Weapons
Frank’s military experience and deep commitment to social issues cre-

ated a desire to understand the psychological aspects of nuclear weapons and
to advocate for policies that fostered peaceful relations among countries. He
wrote an influential article in the Atlantic Monthly (Frank, 1954), served on
the board of National Committee for a Sane Nuclear Policy (SANE), and
published Sanity and Survival: Psychological Aspects of War and Peace (1967,
reissued 1982). For these efforts, he was honored by the American Psycholog-
ical Association in 1985 with the Award for Distinguished Contributions to
Psychology in the Public Interest, for which he wrote another influential arti-
cle, titled “The Drive for Power and the Nuclear Arms Race” (Frank, 1987).
30 WAMPOLD AND WEINBERGER

Psychotherapy Process and Outcome
Frank began his studies of psychotherapy after his discharge from the
armed services, first with the Veterans Administration, where he investigated
group therapy, and then at Johns Hopkins, where he headed a psychiatric out-
patient department. He was uniquely poised to make a contribution because
of his training and his empirical inclinations. At the time (i.e., the 1950s),
the practice of psychotherapy was mostly restricted to psychiatrists. Psychol-
ogists were involved with research design, data collection, and analysis.
Because Frank was both a psychiatrist and a psychologist, he understood
the practice of psychotherapy, research design and statistics, and psycho-
logical principles related to pathology and change processes. This is a unique
set of skills for any period, but particularly so during the infancy of psychother-
apy research.
In Search of Specificity and the Road to Common Factors

Trained in the medical model, Frank initially conceptualized treatment
in terms of specificity. In 1956, he and David Rosenthal (1956) discussed
designing research in psychotherapy to disentangle specific from placebo
effects:
It is concluded that improvement under a special form of psychotherapy
cannot be taken as evidence for: (a) correctness of the theory on which
it is based; or (b) efficacy of the specific technique used, unless improve-
ment can be shown to be greater than or qualitatively different from that
produced by the patients’ faith in the efficacy of the therapist and his
technique—”the placebo effect.” This effect may be thought of as a non-
specific form of psychotherapy and it may be quite powerful in that it
may produce end-organ changes and relief from distress of considerable
duration. (p. 300).
This was cutting-edge thinking. Randomized placebo control group
designs were just emerging in the United Kingdom and the United States and
would not be generally accepted and required for the approval of drugs until
the early 1980s (see Wampold, 2001).
Rosenthal and Frank (1956) noted that comparisons with no-treatment
controls produced ambiguous results because all therapies seemed to work with
some patients and that these benefits could be attributed neither to theory-
specific ingredients nor to nonspecific effects such as expectancy of change.
They concluded,
The only adequate control would be another form of therapy in which
patients had equal faith, so that the placebo effect operated equally in
JEROME D. FRANK 31
both, but which would not be expected by the theory of therapy being
studied to produce the same effects. (Rosenthal & Frank, 1956, p. 300)
In the early studies at Johns Hopkins, Frank and his colleagues set out
to do exactly this: compare various approaches. The obstacles were immense,
as there were no standard treatments (i.e., treatment manuals did not exist
and psychotherapy was learned from one’s supervisor) or outcome measures.
So, the team set about to standardize treatments and use the best outcome
measures that they could cobble together, and they designed a fair compari-
son between group therapy (1.5 hr per week for 6 months), individual ther-
apy (1 hr per week for 6 months), and minimal therapy (.5 hr every 2 weeks
for 6 months). As noted by Frank (1992), “To our astonishment and chagrin,
despite obvious differences in therapies” only one variable, among many,
showed any difference, and the research team was “forced to conclude that
features shared by all three must have been responsible for much of patients’
improvement” (p. 393). And thus was born Frank’s interest in the com-
mon factors! Although he was not the first to discuss common factors (see
Rosenzweig, 1936), Frank’s thinking and research formed the core of the
common factors school of thought for decades to come, culminating in pub-
lication of two editions of Persuasion and Healing (1961, 1973), and another
edition (Frank & Frank, 1991) with his daughter, Julia B. Frank, MD, a tra-
dition carried forth by such luminaries as Arthur Kleinman (e.g., Kleinman
& Sung, 1979), Judd Marmor (e.g., 1962), Sol Garfield (e.g., 1995), and
E. Fuller Torrey (1972).
We should not gloss over the courage that it took to abandon the med-
ical model and embrace what turned into a model embedded in cultural heal-
ing practices, a journey that in many ways took Frank down a path far from
the mainstream. The decision to pursue this line of research and thinking
appears to have emanated from Frank’s commitment to evidence foremost
and his dedicated desire to improve lives, personal values that saturated his
work. Over the years he attributed these values to his training and associa-
tion with colleagues. For example,
Psychiatric training at the Johns Hopkins Hospital under Adolf Meyer
and John C. Whiteborn instilled a nondogmatic outlook, a respect for
facts, and a conviction that systematic observation of individuals in their
social context could yield worthwhile insights into human functioning.
(Frank & Frank, 1991, p. 296)
We suspect that although colleagues may have nurtured these characteristics,
Frank’s fierce belief in evidence and his gentle respect for his fellow humans
were intrinsic characteristics. Parloff and Shapiro (2005), in their American
Psychologist obituary for Frank, quoted Paul McHugh, director of the Depart-
ment of Psychiatry at the Johns Hopkins School of Medicine:

Jerome Frank combined two virtues that you don’t usually find together:
The vigorous virtue of being brave and the gentler virtue of being kind.
He didn’t hesitate to share his views, whether on nuclear war or psycho-
therapy. He did so with clarity, coherence, and with grace (p. 727).
The Common Factor Model

As mentioned previously, Frank was both an empiricist and a theorist,
both a practitioner and a researcher. He followed his data and created a model
of psychotherapy based on the data. For example, Frank extended the idea that
placebo treatments have effects by conducting a study that found improve-
ment in patient functioning to be due to simply being offered treatment (Frank,
Gliedman, Imber, Stone, & Nash, 1959). In this study, minimal contact pro-
duced effects similar to group therapy and individual therapy. Following up on
this, Frank, Nash, Stone, and Imber (1963) administered pretreatment symp-
tom and mood measures. After some further testing, they readministered these
measures. They then administered a placebo pill. Patients showed improved
scores on the measures before they took the placebo. These effects were largely
maintained when the patients returned for second and third visits 1 and
2 weeks later. Even more surprising, there were still measurable effects 3 years
later. Frank therefore discovered that it is possible to get a placebo effect
without a placebo. This finding was subsequently replicated many times
(Friedman, 1963; Kellner & Sheffield, 1971; Piper & Wogan, 1970; Shapiro,
Stuening, & Shapiro, 1980).
This kind of finding is not restricted to therapies practiced decades ago.
It still seems that effects begin before what are thought to be the effective
components of psychotherapy are applied to treatment. For example, Ilardi
and Craighead (1994) looked at studies that followed the temporal course of
improvement in cognitive therapy for depression. They reported that most
positive change had occurred by the 3rd or 4th week of treatment. The spe-
cific techniques targeting depressive thought are not introduced into the
treatment until a few sessions later, however. Moreover, the effects of these
techniques are not presumed to be instantaneous but to develop with time.
Thus, the cognitive techniques of cognitive therapy cannot account for these
positive changes. This is Frank’s finding all over again, this time with a mod-
ern and well-researched treatment that purports to be able to identify the rel-
evant change agents underlying its effects. Whatever else is going on, some,
perhaps most, change in this kind of therapy is not due to the usually identi-
fied factors. Based on these kinds of findings (although the Ilardi & Craighead,
1994, findings came later), Frank (1978) came to the conclusion that posi-
tive expectations are an important factor in psychotherapy. Having taken this
step, he was on his way to his innovative common factors approach. (For
JEROME D. FRANK 33
more recent common factors approaches as well as rejoinders to critiques of
such approaches, see Imel & Wampold, 2008; Wampold, 2007; Weinberger,
1995; Weinberger & Rasco, 2007.)
The common factors model Frank developed diverged radically from his
initial belief that specific factors unique to specific treatments underlay the
effectiveness of psychotherapy. He ended up arguing that radically diverse
forms of psychotherapy have underlying similarities and that their effective-
ness is due to these similarities (Frank, 1973). But his model was richer and
more innovative than merely asserting common factors. He detailed what he
thought those factors were. According to Frank’s model (1973, 1978, 1982;
Frank & Frank, 1991), patients have concluded that they are unable to deal
with issues of importance to them. As a result, they feel incompetent and suf-
fer for it. In Frank’s terminology (e.g., Frank, 1974), they become demoralized.
They hope and expect that psychotherapy can help them overcome these
heretofore insurmountable issues. Once these hopes and positive expectations
are in place, the demoralized state improves.
Although the mere intention to seek help results in some improvement,
the elements of the treatment itself may enhance and solidify positive change.
Additionally, the improvement based on positive expectation and hope needs
to be maintained or it will dissipate over the course of treatment. Through
certain practices, psychotherapy can improve morale beyond the effects of
initial expectations and hopes. All effective psychotherapies, according to
Frank (1973, 1978, 1982), employ four factors that function to mobilize hope
and restore morale. The most important of these is an emotionally charged, con-
fiding relationship with a helping person. Frank averred that such a relationship
is absolutely essential to therapeutic improvement. Recent evidence has sup-
ported Frank’s views on this matter (see, e.g., Weinberger & Rasco, 2007). A
recent task force commissioned by Division 29 (Psychotherapy) of the Amer-
ican Psychological Association conducted a comprehensive review of the
extant data and concluded that the relationship was a (in fact, the) critical
factor in psychotherapy (Norcross, Beutler, & Levant, 2006).
Frank’s second factor was a healing setting. Therapy has to take place some-
where. The therapeutic setting can and usually does symbolize the therapist’s
role as a healer. The setting can be a prestigious hospital or an impressive
office, although even the most humble of settings will usually contain diplo-
mas and impressive-looking books. Whatever the specifics, the setting pro-
vides a cultural context that communicates authority, expertise, and healing
to the patient. All of this helps to enhance the patient’s expectations and
hope that the therapist knows what he or she is doing and can help. It sets
the stage for the therapy and actively affects it. The setting also is a haven. The
patient can feel safe and therefore more open in his or her communications
to the therapist and to the therapist’s interventions.

The third factor is a rationale or myth that plausibly explains the patient’s
difficulties and offers a sensible solution to them. Frank used the term myth
purposely to denote a shared belief system that may or may not be scientifi-
cally true. What is important is that therapist and patient share a belief in this
understanding of psychopathology and treatment. This can range from deep
psychological conflicts originating in early childhood (e.g., Freud, 1917), to
maladaptive ways of thinking (e.g., Beck, 1976), to a reinforcement history that
has conditioned the person to behave maladaptively (Emmelkamp, 1994),
to a lack of necessary skills (Lewinson & Hoberman, 1982), to possession by
demons (Thong, 1976). As long as the myth can be shared, it can function
effectively.
The fourth factor is a believable treatment or ritual for restoring emotional
health. Again, Frank was very conscious of his terms. He referred to a ritual
to highlight the idea that whatever takes place need not be scientifically valid
but that something formal must occur in the course of treatment. A ritual
involves the performance of actions or procedures in a set, ordered (often cer-
emonial) manner. Defined this way, the ritual can be described in a treatment
manual or in the ceremonial treatment of a traditional shaman. In Frank’s
model, these are not different. What is important is that there be a logical
connection between the rituals and the myth that explains the problem.
Thus, lying on the psychoanalytic couch fosters regression to more primitive
states (Freud, 1917), recording of “automatic thoughts” fosters the identifica-
tion of maladaptive thought processes (Beck, 1976), and flooding or system-
atic desensitization extinguishes a maladaptive reinforcement history (Stampfl
& Levis, 1967). This is no different in principle from drinking special potions
and being ministered to by a shaman so that evil spirits can be exorcized (Peters,
1978). To Frank, the key was that the ritual be believable and clearly tied to
the myth.
The equivalence of different forms of therapy flows naturally from Frank’s
model. After all, what makes therapy work is not the specific methods of
the individual schools but what they all have in common, namely, Frank’s
four factors. One implication of this view is that the treatment manuals now
required for clinical trial research do not actually contain within them the
elements of therapeutic success (cf. Weinberger & Rasco, 2007). Rather, they
are an example of a ritual that follows from the myth that one must proceed
in a systematic manner and adhere to a theoretical approach if treatment is
to work. Another implication that flows from Frank’s model is that the ther-
apeutic relationship is critical. Although few dispute this any more, it does
not always garner the attention it should. Some schools of treatment do
not accord it enough importance, if Frank is correct (cf. Weinberger, 1995;
Weinberger & Rasco, 2007). The data seem to support the predictions of
Frank’s model. Outcome equivalence is the rule in psychotherapy outcome
JEROME D. FRANK 35
research (Wampold, 2001; Weinberger & Rasco, 2007), and when it does not
appear, brand loyalty seems to account for the differences (Luborsky et al.,
1999; Wampold, 2001).
CONCLUSION
Jerome Frank was a pioneer in psychotherapy research. His journeys

were guided by critical thinking and empirical results, two hallmarks of rigor-
ous science. His common factors model has stood as a viable alternative to
the dedication to single theories and to the identification of treatments that
purportedly are superior to others. A rereading of his and his Johns Hopkins’
colleagues reminds us that innovative, creative, and rigorous research were
the characteristics of this research program.
REFERENCES
American Psychological Association. (1986). Awards for distinguished contributions

to psychology in the public interest: 1985, Jerome Frank. American Psychologist,
41, 398–405. doi: 10.1037/h0092128
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: Inter-
national Universities Press.
Emmelkamp, P. M. G. (1994). Behavior therapy with adults. In A. E. Bergin & S. L.
Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed.,
Frank, J. D. (1958, November). The great antagonisms. Atlantic Monthly, 202, 58–62.
Frank, J. D. (1967). Sanity and survival: Psychological aspects of war and peace. New
York, NY: Random House.
Frank, J. D. (1973). Persuasion and healing. Baltimore, MD: Johns Hopkins University
Press. (Originally published in 1961)
Frank, J. D. (1974). Psychotherapy: The restoration of morale. American Journal of
Psychiatry, 131, 271–274.
Frank, J. D. (1978). Expectation and therapeutic outcome: the placebo effect and the
role induction interview. In J. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L.
Liberman, & A. R. Stone (Eds.), Effective ingredients of successful psychotherapy
(pp. 1–34). New York, NY: Brunner/Mazel.
Frank, J. D. (1982). Therapeutic components shared by all psychotherapies. In J. H.
Harvey & M. M. Parks (Eds.), The Master Lecture Series: Vol. 1. Psychotherapy
research and behavior change (pp. 5–38). Washington, DC: American Psycholog-
ical Association.

Frank, J. D. (1987). The drive for power and the nuclear arms race. American Psychol-
ogist, 42, 337–344. doi:10.1037/0003-066X.42.4.337
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psy-
choterapy (3rd ed.). Baltimore, MD: Johns Hopkins Univesity Press.
Frank, J. D. (1992). The Johns Hopkins psychotherapy research project. In D. K.
Freedheim (Ed.), A history of psychotherapy: A century of change (pp. 392–396).
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psy-
chotherapy (3rd ed.). Baltimore: Johns Hopkins University Press.
Frank, J. D., Gliedman, L. H., Imber, S. D., Stone, A. R., & Nash, E. H. (1959).
Patient’s expectancies and relearning as factors determining improvement in
psychotherapy. American Journal of Psychiatry,, 115, 961–968.
Frank, J. D., Nash, E. H., Stone, A. R., & Imber, S. D. (1963). Immediate and long-
term symptomatic course of psychiatric outpatients. American Journal of Psy-
chiatry, 120, 429–439.
Freud, S. (1917). Introductory lectures on psychoanalysis: Lecture XXVIII: Analytic
therapy. In J. Strachey (Ed.), The standard edition of the complete psychological
work of Sigmund Freud (Vol. 16, pp. 448–477). London, England: Hogarth Press.
Friedman, H. J. (1963). Patient expectancy and symptom reduction. Archives of
General Psychiatry, 8, 61–67.
Garfield, S. L. (1995). Psychotherapy: An eclectic-integrative approach. New York, NY:
Wiley.
Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-
behavior therapy for depression. Clinical Psychology, 1, 138–156.
Imel, Z. E., & Wampold, B. E. (2008). The common factors of psychotherapy. In
S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed.,
Kellner, R., & Sheffield, B. F. (1971). The relief of distress following attendance at a
clinic. British Journal of Psychiatry, 118, 195–198. doi:10.1192/bjp.118.543.195
Kleinman, A., & Sung, L. H. (1979). Why do indigenous practitioners successfully
heal? Social Science & Medicine, 13B, 7–26.
Lewinson, P. M., & Hoberman, H. M. (1982). Depression. In A. S. Bellack,
M. Hersen, & A. E. Kazdin (Eds.), International handbook of behavior modifica-
tion and therapy (pp. 397–431). New York, NY: Plenum.
Luborsky, L., Diguer, L., Seligman, D. A., Rosenthal, R., Johnson, S., Halperin, G., . . .
Schweizer, E. (1999). The researcher’s own therapeutic allegiances: A “wild
card” in the comparisons of treatment efficacy. Clinical Psychology: Science and
Practice, 6, 95–106. doi:10.1093/clipsy/6.1.95
Marmor, J. (1962). Psychoanalytic therapy as an educational process. In J. H.
Masserman (Ed.), Science and psychoanalysis (Vol. 5, pp. 286–299). New York,
NY: Grune & Stratton.
JEROME D. FRANK 37
Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practices in
mental health. Washington, DC: American Psychological Association.
Parloff, M. B., & Shapiro, D. L. (2005). Jerome D. Frank (1910–2005). American Psy-
chologist, 60, 727. doi:10.1037/0003-066X.60.7.727
Peters, L. (1978). Psychotherapy in Tamang shamanism. Ethos, 6, 63–91.
Piper, W. E., & Wogan, M. (1970). Placebo effect in psychotherapy: An extension of
earlier findings. Journal of Consulting and Clinical Psychology, 34, 447. doi:10.1037/
h0029345
Rosenthal, D., & Frank, J. D. (1956). Psychotherapy and the placebo effect. Psycho-
logical Bulletin, 53, 294–302. doi:10.1037/h0044068
Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psycho-
therapy: “At last the Dodo said, ‘Everybody has won and all must have prizes.’”
American Journal of Orthopsychiatry, 6, 412–415.
Shapiro, A. K., Struening, E., & Shapiro, E. (1980). The reliability and validity of
a placebo test. Journal of Psychiatric Research, 15, 253–290. doi:10.1016/0022-
3956(79)90016-5
Stampfl, T. G., & Levis, D. J. (1967). The essentials of implosive therapy: A learning-
theory-based psychodynamic behavioral therapy. Journal of Abnormal Psychology,
72, 496–503. doi:10.1037/h0025238
Thong, D. (1976). Psychiatry in Bali. Australian and New Zealand Journal of Psychiatry,
10, 95–97.
Torrey, E. F. (1972). What Western psychotherapists can learn from witch doctors.
American Journal of Orthopsychiatry, 42, 69–76.
Wampold, B. E. (2001). The great psychotherapy debate: Model, methods, and findings.
Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment.
American Psychologist, 62, 857–873. doi: 10.1037/0003-066X.62.8.857
Weinberger, J. (1995). Common factors aren’t so common: The common factors
dilemma. Clinical Psychology: Science and Practice, 2, 45–69.
Weinberger, J., & Rasco, C. (2007). Empirically supported common factors. In
S. G. Hofmann & J. Weinberger (Eds.), The art and science of psychotherapy
(pp. 103–129). New York, NY: Routledge.

4
LESTER LUBORSKY: A TRAILBLAZER
IN EMPIRICAL RESEARCH ON
PSYCHOANALYTIC THERAPY
PAUL CRITS-CHRISTOPH, JACQUES P. BARBER,
BRIN F. S. GRENYER, AND LOUIS DIGUER
Lester Luborsky, who died in October 2009 at the age of 89, was one of
the pioneers of psychotherapy research. His career began in the 1950s and
only ended with his retirement in 2006. We are lucky to be intimately famil-
iar with Lester’s ideas and contributions throughout his career through our
long-standing collaborations with him. We have benefited enormously from
Lester’s productivity, creativity, and perseverance in completing studies and
projects. In this chapter we hope to provide a sense of his contributions to the
field of psychotherapy research, not only in terms of his publications but also
his personal influences on others.
MAJOR CONTRIBUTIONS
Lester Luborsky contributed in a variety of ways to many aspects of cur-

rent psychotherapy research. His major contributions can be summarized in
terms of the following broad themes.
39
Articulation of a Theory of Symptom Formation
A major theme in Luborsky’s early research, but also continuing up to

his retirement, was a focus on understanding the onset conditions for the
appearance of both psychological and somatic symptoms during therapy ses-
sions. His method, which he called the symptom-context method, involved the
comparison of the material that had preceded the appearance of symptoms to
sections of a session preceding a control event (i.e., a randomly selected event
that was not describing the appearance of symptom). This work is summa-
rized in his Symptom-Context Method: Symptoms as Opportunities in Psychother-
apy, published in 1996.
Studies of Central Relationship Patterns
Perhaps Luborsky’s most influential contribution later in his career

was the quantitative study of relationship patterns in psychotherapy. The
method Luborsky invented—the core conflictual relationship theme (CCRT)
method—was a breakthrough in the operationalization of clinical psycho-
dynamic concepts.
Studies of the Patient–Therapist Relationship
Luborsky developed one of the first scales to measure the therapeutic

alliance in psychotherapy. This area of research went on to become perhaps
the most highly researched aspect of the process of psychotherapy.
Development of a Treatment Manual for Brief Psychodynamic Therapy
Luborsky published one of the first psychodynamic treatment manuals.

This contribution set the stage for the evaluation of the efficacy of this com-
mon form of psychotherapy.
Studies of Predictors of Therapeutic Outcome
Many of Luborsky’s publications dealt with attempts to predict treat-

ment outcome from patient, therapist, or process variables. The Penn
Psychotherapy Project was a large-scale study conducted by Luborsky and
colleagues designed to broadly assess the full range of potential predictors
of outcome.
40 CRITS-CHRISTOPH ET AL.
Studies of the Efficacy of Supportive–Expressive Psychotherapy
Early on, Luborsky collaborated with George Woody, Thomas McLellan,

and Charles O’Brien on two studies of supportive–expressive therapy for
patients with opiate dependence. In fact, this work is one of the few where
a dynamic therapy for a specific disorder was replicated. This work led to addi-
tional studies of Luborsky and his colleagues looking at supportive–expressive
therapy for major depressive disorder, generalized anxiety disorder, person-
ality disorders, and cocaine dependence.
An Influential Review of the Literature on the Comparative Efficacy

of Different Psychotherapies
In a widely cited classic publication, Luborsky, Singer, and Luborsky

(1975) concluded from a qualitative review of about a hundred compara-
tive treatment studies that all active treatments were equally effective. This
convinced Luborsky of the importance of common factors across different
psychotherapy.
EARLY BEGINNINGS
Lester Luborsky was born in 1920 and grew up during the Great Depres-
sion in Philadelphia, where he played in fields that disappeared as what was a
town became a sprawling city. His family originated from Eastern Europe.
After high school graduation, Luborsky took a research assistant job at Penn
State to pursue his passion, botany. But while at Penn State he came across
some of the works of Freud in his landlady’s bookcase, and these books—
together with a desire to work with people rather than plants—set the course
of his future career. Luborsky then attended college at Temple University and
graduated at the age of 22 with a bachelor of arts degree. He then proceeded
to Duke University in North Carolina for his master’s and PhD in psychology.
Even after turning to psychology and psychotherapy as his vocation,
the theme of botany continued to be apparent throughout Luborsky’s life
and career. His passion for botany stemmed from a delight in what he termed
“watching things grow”—which he later used as a natural basis for studying
patients’ growth and change over the course of psychotherapy. This theme
was also placed by Luborsky on the last page (1984, p. 180) of his psycho-
dynamic psychotherapy manual through an illustration showing the watering
of a plant alongside a magnifying glass. These two symbols convey how the
LESTER LUBORSKY 41
therapist provides the conditions and nutrients for growth and also provides
a close examination of the thoughts, feelings, desires, and behaviors of the
patient. One relevant memorable anecdote regarding botany was when, dur-
ing Luborsky’s training, he was discussing an idea with Eric Erikson. There
was some contention between Luborsky and Erikson, but Erikson diplomat-
ically replied that Luborsky’s ideas “needed some watering.” Also linked with
Luborsky’s interest in botany and gardening was that of rearranging stones
and rocks within a natural setting (in the style of Japanese Zen rock gardens),
an activity he pursued both in terms of the features in his own garden (which
he tended religiously) and in miniature at his work desk. Luborsky’s portrait,
which hangs in the University of Pennsylvania Medical School, shows him
with some rocks, an intentional reference to this aspect of his life and its
influence on his other thinking.
Luborsky’s PhD thesis, completed in 1945 and developed in the context
of World War II, was on the topic of visual perception of aircraft recognition.
Around this time his work for Raymond Cattell spurred his interest in psycho-
logical measurement. Following several positions at Duke and then the Uni-
versity of Illinois, Luborsky cemented his interest in Freud and psychoanalysis
when he obtained a research post in 1946 at the world-renowned Menninger
Foundation. The Menninger Foundation over the course of Luborsky’s years
there was a hotbed of influential psychoanalytic thinkers and researchers,
including David Rapaport, Karl Menninger, George Klein, Roy Schafer, Philip
Holzman, Herbert Schlesinger, Howard Shevrin, Merton Gill, Otto Kernberg,
Robert Holt, and Robert Wallerstein. These individuals had an enormous influ-
ence on Luborsky’s clinical training and research ideas. While working within
the Menninger clinic research program, he was offered and accepted full psy-
choanalytic training with the affiliated Topeka Psychoanalytic Institute. This
was at the time a rare opportunity, as psychologists generally were unable to
obtain psychoanalytic training, and he was able to integrate his analysis with
his paid work, making his analytic training affordable and possible.
His 13 years (1946–959) in Kansas at the Menninger Foundation were
critical to shaping much of the direction of Luborsky’s future research, for it
was here that he worked on one of the first empirical studies of psychoana-
lytic psychotherapy, the Menninger Foundation Psychotherapy Research
Project. In those years, research on psychotherapy and psychoanalytic was in
its infancy. Important researchers at the time who were influences included
Henry Murray and Christina Morgan at Harvard. Components of their work
with the Thematic Apperception Test were probably influential in the later
development of the tripartite structure of Luborsky’s CCRT method.
Luborsky was offered, and accepted, a post at the University of Pennsyl-
vania in 1959. Aaron Beck was on the panel that supported his professorship.
The move “back home” to Philadelphia was his last career move, and he was
highly productive at Penn until his retirement in 2006. The move to Penn
allowed him to take leadership of projects and ideas that had been germinat-
ing in Kansas, and major projects began to emerge, including the Penn Psy-
chotherapy Research project. Throughout most of his years at Penn, he was
not only a researcher but actively involved as a clinical psychotherapist and
a teacher of psychotherapy. He was highly sought after as a clinical super-
visor and won an award within the Department of Psychiatry for his teach-
ing of psychiatric residents and postdoctoral fellows.
ACCOMPLISHMENTS
In regard to specific contributions, we focus our brief review of Lester

Luborsky’s research accomplishments around a selection of some of his more
influential and classic papers, taking them in historical order and placing
them within the context of the science of psychotherapy, and his personal
odyssey, of the time.
How does a career in psychotherapy research begin? For Luborsky, it
began with a challenge that motivated him through much of his career. This
challenge came in the form of a paper published in 1952 by the famous British
psychologist Hans Eysenck. In this paper, Eysenck claimed that psychother-
apy produced changes no larger than what is evident from the passage of time.
Luborsky wrote a rebuttal to Eysenck’s paper (Luborsky, 1954) arguing that
Eysenck’s control group (insurance company data) was flawed, as was the
assessment of outcome. Eighteen years later, Luborsky (1972) again wrote a
response to Eysenck, reiterating and extending some of his earlier points. For
much of the rest of his career, he often spoke about the impact that Eysenck’s
paper had on him. The extensive research on psychotherapy outcome that
was generated in the 1970s, 1980s, and 1990s, leading to the widespread con-
sensus that Eysenck was wrong and that psychotherapy was effective, gave
Luborsky satisfaction that the debate had been settled in Luborsky’s favour.
Once you have decided to devote your career to the study of psychother-
apy, what do you do first? The first step is to create valid ways of measuring the
outcome of treatment. So this is where Luborsky began. One particular task he
had within the context of the Menninger Foundation Psychotherapy Research
Project was to help develop a measure of psychological health–sickness.
Before the publication of the Diagnostic and Statistical Manual of Mental Dis-
orders (DSM; 1952) and the current focus on syndromes and symptoms,
psychotherapy was applied to the broad range of patients appropriate for
outpatient treatment. Luborsky’s work in this area led to the development
of the Health–Sickness Rating Scale (HRSR; Luborsky, 1962). Although
simple, this rating scale has been extremely useful in clinical research. With
LESTER LUBORSKY 43
minor changes, the HRSR became the basis for the widely used Global Assess-
ment of Functioning scale in the DSM.
Like any fledgling field of study, an early step in the development of the
evolving field of psychotherapy research was to hold a consensus conference
to map out the primary issues and problems that needed to be addressed.
An initial consensus conference was held in 1958. The second, and more sig-
nificant, consensus conference was held in 1961. Luborsky was prominently
involved in the planning and implementation of this consensus conference,
and participated as an editor of a book that summarized the conference find-
ings (Strupp & Luborsky, 1962). His collaboration with Hans Strupp on this
volume marked the beginnings of a lifelong friendship and friendly competi-
tion with Strupp. As Strupp remarked to a Vanderbilt graduate student who
had worked in Luborsky’s research program, he and Luborsky were the “Macy’s
and Gimbels” (an allusion to the department stores’ legendary rivalry) of psy-
chodynamic psychotherapy research—often pursuing similar research agen-
das and each keeping a close eye on what the other was doing.
After coming to the University of Pennsylvania, Luborsky obtained a
major grant, in 1968, from the National Institute of Mental Health (NIMH)
to conduct a 5-year comprehensive study of the factors that influence the out-
come of psychotherapy. This study, later named by Luborsky the “Penn Psy-
chotherapy Project,” was the primary source of data and transcripts for a large
number of his subsequent papers, chapters, and books for the rest of his career.
At the same time he received the NIMH grant to conduct the Penn Psy-
chotherapy Project, Luborsky applied for and received a Research Scientist
grant (K-award) from NIMH (1968–1973). He would obtain renewals of
this Research Scientist grant from NIMH from 1973 to 1992, and he then
received similar awards from 1992 to 2000 from the National Institute on
Drug Abuse.
Luborsky’s interest in examining predictors of therapy outcome origi-
nated from his experiences working at the Menninger Foundation before
coming to the University of Pennsylvania. The Menninger Foundation Psy-
chotherapy Research Project also had the goal, among other goals, of exam-
ining predictors of treatment outcome. However, he left the Menninger
Foundation before the study came to fruition. This seemed to motivate him,
as he described in the acknowledgment section of the 1988 book, Who Will
Benefit From Psychotherapy? Predicting Therapeutic Outcomes, to conduct his
own study that would make use of the strengths but rectify the weaknesses of
the Menninger study. Another input to his interest in examining predictors
of therapy outcome was his previous work at Menninger’s with Robert Holt
on predictors of which physicians would make good psychiatrists (Holt &
Luborsky, 1958). The difficult issues in the work with Holt regarding the
assessment of outcome and how to manage a large number of predictors helped
Luborsky address similar methodological concerns when working on a com-
prehensive study of predictors of therapy outcome.
In preparation for conducting the Penn Psychotherapy Project, Luborsky
and colleagues published in the Psychological Bulletin a review of all previous
studies examining predictors of therapy outcome. This review (Luborsky et al.,
1971) became highly influential, eventually receiving recognition as a “citation
classic” by the Science Citation Index in 1981.
In 1975, Luborsky and colleagues published another highly cited and
influential paper reviewing the literature to date on comparative studies of
psychotherapies. The subtitle of the paper, “Everyone Has Won and All Must
Have Prizes,” was taken from the verdict of the dodo bird commenting on a
race in Lewis Carroll’s famous Alice’s Adventures in Wonderland. Originally
applied by Rosenzweig (1936) in a clinical analysis to convey the sense that
diverse psychotherapies achieve comparable success owing to common fac-
tors, Luborsky’s borrowing of the dodo’s verdict to summarize his seminal
review of the comparative effects of different psychotherapies has had a last-
ing impact on psychotherapy research. Since the publication of his paper, it
is actually rare to see a paper that addresses comparative effects of psychother-
apies that does not make reference to the “dodo bird verdict” and Luborsky’s
paper, either in support of his conclusion or attempting to refute it.
The primary results of the Penn Psychotherapy Project took several
years to appear in print, with the full set of results published in book form later
(Luborsky et al., 1988). The delay in publishing the results of the Penn Psy-
chotherapy Project (data collection was finished in 1973, but the first primary
paper giving results appeared in 1979) was probably due to a number of fac-
tors. One was that the funding for the study had ended and Luborsky’s pri-
mary collaborator, Jim Mintz, who had provided the methodological and
statistical expertise for the study, had moved on to another job. A second
factor is that the results of the study were largely negative: The outcomes of
psychotherapy were not very predictable from pretreatment information on
patients or therapists. Luborsky always preferred to tell a positive message
about his research studies, commenting once (to Paul Crits-Christoph) that
“there are two types of researchers, those that say there is nothing in the data
and those that say there is something in the data.” The lack of findings left
Luborsky searching for something to say. This then eventually spurred him to
attack the question anew: If pretreatment factors mattered little, what deter-
mined the outcome of psychotherapy?
The answer, of course, was that aspects of the process of psychotherapy
were particularly important to treatment outcome. The immediate stimulus
for Luborsky’s turning to creating new measures for studying the process of
psychotherapy was his participation in a panel at the Society for Psychother-
apy Research meetings in 1975. It was at this panel that Ed Bordin introduced
LESTER LUBORSKY 45
his influential ideas on the concept of the working alliance. In preparation
for the meeting, Luborsky began looking closely at transcripts of sessions from
the Penn Psychotherapy Study to see if he could devise a way of measuring the
alliance. The result was the creation of observer-rated scales to measure
the helping alliance (Luborsky’s term for what others referred to as the thera-
peutic alliance or working alliance), which he first published in a book chapter
(Luborsky, 1976). He subsequently published on the development of an
alliance questionnaire and conducted a variety of studies looking at the role
of the alliance in psychotherapy.
In many ways it appears as though Luborsky’s success at inventing a
scale to measure the alliance unleashed his creativity and energies that set the
stage for the rest of his career. Much of his research on psychotherapy up to
this point (1975) was atheoretical in nature. The breakthrough of seeing that
a central clinical notion like the alliance could be measured allowed him and
others to ask further theoretically and clinically important questions about
the process and outcome of psychotherapy, particularly psychodynamic psy-
chotherapy. This shift in creative energies is evident in Luborsky’s productiv-
ity: From 1945 to 1975 he published 87 publications and from 1975 to 2005
he published over 300 more.
Immediately after developing a measure of the alliance, Luborsky turned
his attention to another key aspect of clinical psychodynamic psychotherapy:
the assessment of the patient’s central relationship theme. The concept of the
CCRT was initially formulated in 1977 (Luborsky, 1977). With the CCRT,
Luborsky wished to reach with empirical tools the deepest roots of clinical
psychodynamic practice, that is, the transference, which is regarded as the
keystone and the most specific characteristic of psychoanalytic and psycho-
dynamic treatments. His efforts at measuring this element of psychotherapy
were very productive. Numerous studies used the CCRT in a variety of con-
texts (summarized in Luborsky & Crits-Christoph, 1998). Further, the work
on the CCRT fostered the emergence of other measures and methodologies
that aim at exploring psychotherapy processes that were thought before to be
too difficult to approach empirically.
The CCRT was also an important component of one of Luborsky’s other
most influential contributions: the codification of supportive–expressive psy-
chodynamic psychotherapy in a treatment manual (Luborsky, 1984). After
emerging from a period of “generic” or atheoretical psychotherapy research,
Luborsky had now turned back completely to his psychoanalytic roots that
were nurtured at the Menninger Foundation. The concept of a treatment
manual—a guide to assist in the training of therapists and the standardization
of treatment—was new to psychotherapy research. As part of his clinical
teaching of therapy, Luborsky had developed in 1976 a rough unpublished
guide to training psychodynamic psychotherapists called The Task of the Psy-
chotherapist. Sensing that a more formal treatment manual would help move
the scientific study of psychodynamic therapy forward, he embarked on a
systematic description of how to do what he felt was typical psychodynamic
therapy. His model for the treatment was the supportive–expressive therapy
taught at the Menninger Foundation. A further impetus for Luborsky’s mov-
ing quickly on publishing his manual was the knowledge that Hans Strupp
was also working on a guide to psychodynamic therapy. Both treatment man-
uals were published in 1984 with the same publisher (Strupp & Binder, 1984;
Luborsky, 1984).
Luborsky’s supportive–expressive treatment manual became a major suc-
cess both clinically and in research circles. The manual was frequently used as
a training device in graduate programs and psychiatric residencies. The man-
ual, together with more specific addendums tailoring the treatment to specific
patient population, served as the basis for studies of supportive–expressive ther-
apy for generalized anxiety disorder, chronic depression, cocaine dependence,
personality disorders, opiate dependence, and cannabis dependence.
Beyond his publications, Luborsky influenced psychotherapy research
in many other ways. He was the fourth president (1973–1974) of the Society
for Psychotherapy Research (SPR), the only professional conference that he
regularly attended. Across a span of 32 years (from the first meeting in 1970
to 2002), we are aware of only one annual SPR meeting that he did not
attend, presenting a paper at each and every meeting he attended.
Not being in a psychology department, Lester did not work directly with
graduate students as an advisor. However, within the Department of Psychia-
try at the University of Pennsylvania, his influence as a clinical teacher of psy-
chiatric residents and postdoctoral fellows was enormous. His model of clinical
supervision was a group one. This group supervision was a sought-after aspect
of the psychiatric residency—with four to five residents or postdoctoral fellows
participating every year for the more than 25 years that he offered this group.
While other psychodynamic supervisors relied on the overwhelmingly large
and diverse psychoanalytic literature as the base for their teaching, Luborsky’s
approach to psychodynamic therapy, anchored in his supportive–expressive
therapy manual and the CCRT formulation, provided an understandable entry
into the complex psychoanalytic arena. Thus, Luborsky was typically the first
supervisor who made a generation of clinical trainees at the University of
Pennsylvania comfortable with the ambiguous task of being a therapist.
Within the research domain, Luborsky had a major influence on a num-
ber of young PhDs or MDs who were junior faculty at the University of Penn-
sylvania and went on to have careers in psychotherapy research. Art Auerbach
joined Luborsky at the beginning of the Penn Psychotherapy Project and con-
tinued working closely with him for about a decade. Jim Mintz was the proj-
ect director of the Penn Psychotherapy Project. Paul Crits-Christoph and
LESTER LUBORSKY 47
Jacques Barber were also hired by Luborsky as junior faculty in the Department
of Psychiatry. All four of these investigators went on to become presidents of
SPR. By this metric, Luborsky mentored significantly more future presi-
dents of SPR than did any other senior psychotherapy researcher in history.
Other significant collaborators at the University of Pennsylvania were Tom
McLellan, George Woody, and Charles O’Brien. Luborsky also had an influ-
ence internationally, developing strong collaborations with investigators and
clinicians in Germany (Horst Kächele), Canada (Louis Diguer, Howard Book),
and Australia (Brín Grenyer), among others.
CONCLUSION
Luborsky’s work—particularly his writings on predictors of outcome, the

CCRT, supportive–expressive therapy, comparative studies of psychother-
apies, and the alliance—has had a broad influence on the field of psy-
chotherapy and beyond. From the broadest perspective, perhaps his lasting
legacy is in demonstrating that highly sophisticated clinical concepts about
psychotherapy could be measured and validated. When a large faction of the
field viewed psychotherapy as more of an art form that could not be rigorously
studied, Luborsky was determined to show otherwise. Although he valued
and respected the work of Sigmund Freud enormously, Luborsky’s career was
focused in a direction different from Freud’s. In fact, in the 1930s, after receiv-
ing a letter from Saul Rosenzweig that described the results of experimental
studies of some psychoanalytic concepts, Freud said that psychoanalysis had
no need of such studies, because clinical observation was sufficient to estab-
lish the usefulness of the psychoanalytic concepts. In contrast to Freud,
Luborsky was doggedly determined to show that quantitative studies of psy-
choanalytic concepts and therapy were useful and could more rigorously val-
idate such constructs. To the extent that he succeeded in this agenda in
multiple ways, the practice of psychotherapy and the scientific study of psy-
chotherapy have both benefited enormously from Luborsky’s career.
REFERENCES
American Psychiatric Association. (1952). Diagnostic and statistical manual of mental

disorders. Washington, DC: Author.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Con-
sulting Psychology, 16, 319–324. doi:10.1037/h0063633
Holt, R. R., & Luborsky, L. (1958). Personality patterns of psychiatrists: A study in selec-
tion techniques (Vol. 1). New York, NY: Basic Books.
Luborsky, L., & Crits-Christoph, P. (Eds.). (1998). Understanding transference: The
core conflictual relationship theme method (2nd ed.). Washington, DC: American
Luborsky, L. B. (1954). A note on Eysenck’s article: The effects of psychotherapy: An
evaluation. British Journal of Psychology, 45, 129–131.
Luborsky, L. (1962). Clinician’s judgments of mental health: A proposed scale.
Archives of General Psychiatry, 7, 407–417.
Luborsky, L. (1972). Another reply to Eysenck. Psychological Bulletin, 78, 406–408.
doi:10.1037/h0020022
Luborsky, L. (1976). Helping alliances in psychotherapy: The groundwork for a study
of their relationship to its outcome. In J. L. Claghorn (Ed.), Successful psychother-
apy (pp. 92–116). New York, NY: Brunner/Mazel.
Luborsky, L. (1977). Measuring a pervasive psychic structure in psychotherapy:
The core conflictual relationship theme. In N. Freedman & S. Grand (Eds.),
Communicative structures and psychic structures (pp. 367–395). New York, NY:
Plenum Press.
Luborsky, L. (1984). Principles of psychoanalytic therapy. A manual for supportive-
expressive treatment. New York, NY: Basic Books.
Luborsky, L., Chandler, M., Auerbach, A. H., Cohen, J., & Bachrach, H. M. (1971).
Factors influencing the outcome of psychotherapy: A review of quantitative
research. Psychological Bulletin, 75, 145–185. doi:10.1037/h0030480
Luborsky, L. (1996). (Ed). Symptom-Context Method—Symptoms as opportunities in
psychotherapy. Washington: American Psychological Association.
Luborsky, L., Crits-Christoph, P., Mintz, J., & Auerbach, A. (1988). Who will bene-
fit from psychotherapy? Predicting therapeutic outcomes. New York, NY: Basic
Books.
Luborsky, L., Singer, B., & Luborsky, Lise. (1975). Comparative studies of psychother-
apies: Is it true that “Everyone has won and all must have prizes”? Archives of
Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psy-
chotherapy. The American Journal of Orthopsychiatry, 6, 412–415.
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-
limited dynamic psychotherapy. New York, NY: Basic Books.
Strupp, H. H., & Luborsky, L. B. (Eds.). (1962). Research in psychotherapy. [Proceed-
ings of a conference held in Chapel Hill, NC, May 1961.] Washington, DC:
American Psychological Association.
LESTER LUBORSKY 49
5
HANS STRUPP: A FOUNDER’S
CONTRIBUTIONS TO
A SCIENTIFIC BASIS FOR
PSYCHOTHERAPY PRACTICE
KARLA MORAS, TIMOTHY ANDERSON, AND WILLIAM E. PIPER
Hans Hermann Strupp’s passion for psychotherapy practice and research

fueled pioneering contributions to both and brought international influence and
acclaim to this famously modest man. He stands among the most widely read,
thoughtful, ecumenical, and avid scholar–scientist–clinicians in psychotherapy
and therapy research during the latter half of the 20th century. Even his early
writings and therapy research remain broadly cited and influential.
Beginning with his dissertation proposal in 1953, Hans Strupp’s contri-
butions coincided with and helped shape the coalescence of therapy research
into a bona fide field in the United States. An auxiliary but key role was to
serve both research and practice as a bridge builder. For example, he supported
Goldfried’s proposal that the power of psychotherapy might be increased by
integrating theoretically diverse, and often warring, schools of therapy that
dominated the emerging scene into the 1980s (e.g., Goldfried, 1982). Strupp
continually pursued a variety of ways to close the refractory gap between prac-
tice and research (e.g., Strupp, 1989). As a researcher, he applied rigorous sci-
entific methodology with a master practitioner’s sensibilities for understanding
the complexity of both psychotherapy and therapy research data. Two of his
particularly well-known studies, popularly referred to as “Vanderbilt I” and
“Vanderbilt II,” illustrate the point. Both were conducted during the 3rd and
51
4th decades of his career while he was a Distinguished Professor at Vanderbilt
University (Bein et al., 2000; Henry, Strupp, Butler, Schacht, & Binder, 1993;
Strupp, 1993; Strupp & Hadley, 1979).
Hans Strupp remained an active, leading figure until about the year
2000, when his eloquent and incisive clinical–theoretical and research writ-
ing (e.g., Strupp, 1977) was increasingly challenged by Parkinson’s disease.
Hans’s sonorous voice and charming, subtle wit stayed with us longer. His
impact as mentor, colleague, and model for conducting one’s life in ways that
honor being human are as legendary as they are enduring.
MAJOR CONTRIBUTIONS
Hans Strupp is recognized for numerous major contributions. Perhaps

most crucial, given the vulnerable, nascent periods of psychotherapy research
and clinical psychology during which Strupp entered both fields, was his stal-
wart advocacy of a fundamental—yet often controversial—principle: A scien-
tific basis for clinical practice is required. Although Strupp remained profoundly
influenced by Freud’s writings, he departed fundamentally from Freud by insist-
ing on the need for scientific testing of efficacy and other claims about all
forms of psychotherapy, including psychoanalysis (Bergin, 2007; Strupp,
1976b). More broadly, Strupp remained a resolute, even courageous, voice for
excellence and responsible professionalism in all aspects of clinical psychology
(training, practice, research) when anti-intellectual, antiscientific, and related
ideas gained popularity both within the field of clinical psychology and as
sociopolitical forces in the United States (Strupp, 1976a).
Strupp’s contributions advanced knowledge on several core practice-
relevant questions, notably: What are the key mechanisms of action of
psychotherapy as a generic treatment modality? What are the implications for
evaluating psychotherapies of the recurrent finding that interested parties, such
as patient, therapist, and society’s representatives, often do not closely agree on
outcomes (Strupp & Hadley, 1977)? What is the therapist’s contribution? and,
importantly, What are the impacts of therapists’ negative reactions to patients,
and how can such reactions be managed to avoid compromising the potential
benefits of therapy or, worse, promoting negative effects?
What might Strupp cite as his major contributions? He emphasized two
conclusions near the close of his career on questions that were both central
to the field and lifelong foci of his research (e.g., Henry & Strupp, 1992;
Strupp, 1993, 1995).
䡲 Conclusion 1. The nonspecific vs. specific factors model of
therapeutic influence is fatally flawed as a general model of the
52 MORAS, ANDERSON, AND PIPER

action of psychotherapy and cannot productively guide research
(Strupp, 1995).
䡲 Conclusion 2. “The quality of the interpersonal context is the
sine qua non in all forms of psychotherapy” (Strupp, 1995, p. 70,
italics in original). Further, a major barrier to optimal thera-
peutic benefits is inadequate therapist skill in managing the
interpersonal context of psychotherapy, particularly therapists’
negative attitudes and behaviors toward patients. Therapeu-
tic work carries with it a ubiquitous vulnerability to problems
in the interpersonal context, which merits being the core
focus of professional therapist training (Henry & Strupp, 1992;
Strupp, 1995).
EARLY BEGINNINGS
The path to Hans Strupp’s prodigiously successful career was neither

easy nor obvious. He was born in Frankfurt am Main, Germany (August 25,
1921), less than 3 years after World War I. When he was 9 years old, Strupp
was sent away to live briefly with an uncle because his father was ill. He was
unaware of the gravity of his father’s condition until he was told that his
father had died, whereupon, he vividly recalled, he was whisked away to a
local religious leader and declared head of the family.
Hans’s early education was interrupted when Nazi influences made
public schools problematic for Jewish students. When he was about 16, Hans’s
mother decided that he had best leave the school system. His education con-
tinued via private language lessons and work as an apprentice, focused on
basic office skills and translation—to enhance the family’s chances to immi-
grate to the United States. After a close encounter with the anti-Semitic fury
of the Kristallnacht, he fled at age 17 from Nazi Germany to the United
States with his mother and only sibling, a younger brother. They landed in
New York City, where Hans worked as a bookkeeper but soon was offered a
job transfer with higher salary in the Washington, DC, area. There, the fam-
ily lived in an apartment from about 1940 to 1951 in an arrangement that
Strupp described with affectionate wit as a “folie-à-trois.” Into adulthood,
Hans’s prescribed role and sense of duty as head of the family endured: His
advanced education was delayed and prolonged by working as a bookkeeper
to provide for his mother. In 1951, his home situation changed when he mar-
ried Lottie Metzger, who became the mother of their three children and his
lifelong partner.
Strupp completed bachelor’s and master’s degrees at George Washing-
ton University via night school. His choice of an undergraduate major in
HANS STRUPP 53
psychology was primarily due to pragmatic postdegree employability consid-
erations, rather than to the field’s intrinsic appeal to him, at least as it was
taught at the time. The same was not true of Freud’s writings. In Strupp’s
(n.d.) words:
Freud’s writings captivated me and opened horizons of unimaginable pro-
portions. Untutored as I was in psychoanalysis, much of what I read
escaped me but what I did comprehend left a deep impression. No other
writer had a comparable effect on my life. Freud has remained one of my
great heroes, the other being Mozart.
A fellow student, also a German refugee, serendipitously introduced
Strupp to Freud’s works in about 1940. By 1946, Strupp pursued clinically ori-
ented experiences, including a personal psychoanalysis, at the Washington
School of Psychiatry (WSP). The WSP was renowned for the interpersonal
model of one of its founders, Harry Stack Sullivan (Sullivan, 1953). Hans’s
decision to apply to the WSP was likely bolstered in 1945 by a chance meet-
ing with Frieda Fromm-Reichman, also a German refugee, who taught at
WSP and was a prominent psychiatrist at the famous Chestnut Lodge in
Maryland. Strupp never forgot “her indelible injunction: The therapist listens”
(Strupp, n.d., italics in original). He seemed to agree that “it is the crux of
all psychotherapy.”
The completion of his doctorate in 1954, when Strupp was 32 years
old, launched his psychotherapy research career. Although his doctoral sub-
specialty was social psychology, his dissertation project was psychotherapy
research. Strupp received instant and strong reinforcement for the effort. His
dissertation yielded three articles, all published in 1955 and in the most pres-
tigious, then and now, clinical research journal of the American Psycholog-
ical Association (e.g., Strupp, 1955), the Journal of Consulting and Clinical
Psychology.1
Strupp’s “heart’s desire” became “to become a clinical psychologist,” but
he encountered difficulty because his educational background was not the
accepted route to the profession (Strupp, n.d.). A hurdle he could not clear
even with doctorate in hand was the lack of a predoctoral internship. Unsuc-
cessful applications for clinical positions and his signature persistence culmi-
nated in 1955 with a success—a grant from the National Institute of Mental
Health (NIMH) for a therapy research project. Strupp always believed that
Jerome Frank, a reviewer of the grant application (Strupp’s first) with whom
he met during the review process, was integrally responsible. To Strupp, the
grant was “one of the greatest strokes of luck in [his] professional career”
(Strupp, n.d.).
1Formerly, Journal of Consulting Psychology.

ACCOMPLISHMENTS AND HONORS
Strupp published on or otherwise contributed to most, if not all, of the

core issues and questions in therapy research and practice from the 1950s into
the new millennium. Also, and important, his primary allegiance was always to
advancing the potential effectiveness of psychotherapy as a treatment modal-
ity. Thus, while his sentiments remained closest to the psychodynamic perspec-
tive, he carefully evaluated the potential of other theoretical models, such as
learning theory, to inform the effort. He both contributed to efforts to identify
therapeutically potent elements of, and commonalities between, theoretically
different forms of therapy (e.g., Strupp, 1973) and encouraged the efforts of
others (Paul Wachtel, Marvin Goldfried) to do so.
Strupp received many prestigious awards, including the American Psy-
chological Association’s (APA) Distinguished Professional Contributions to
Knowledge Award, the Society for Psychotherapy Research’s (SPR) Distin-
guished Research Career Award, and an honorary Doctor of Medicine from
the University of Ulm. Strupp treasured SPR, an organization of which he
was a founding member and third president. In 1998, the American Psycho-
analytic Association awarded him honorary membership
. . . in recognition for his exploration of psychoanalytic science over
many decades in academic settings rife with skepticism about psycho-
analysis and his contributions toward legitimizing psychoanalytic thought
and investigation in graduate and postgraduate education in psychology
(Strupp, n.d.).
The award carried some irony: Around 1960, Strupp had been denied a deeply
cherished goal—to receive psychoanalytic training at an officially recognized
psychoanalytic institute. Full psychoanalytic training was closed to non-MDs
despite Freud’s explicit statements that psychoanalysis was distinct from med-
icine and properly separated from it.
Only a few accomplishments are highlighted in this short chapter. They
are described mostly in chronological order to convey milestones that led to
Strupp’s two major conclusions, previously noted.
From Serendipitous Early Findings to Scientific, Practice,

and Training Foci
In Strupp’s view, his most constant goal was to elucidate how therapists
can purposefully and consistently potentiate beneficial effects—and also avoid
the opposite. The latter came to be a primary focus as his career progressed.
His keen interest in the therapist’s contribution is traceable to his first therapy
study, his dissertation (e.g., Strupp, 1955). It and other of his early studies led
HANS STRUPP 55
to what Strupp called a “serendipitous finding” that became a central, guid-
ing thread (Henry & Strupp, 1992):
I adduced evidence that negative attitudes toward a patient tended to
be associated with unempathic therapist communications and unfavor-
able clinical judgments, whereas the opposite was true of respondents
who felt more positively toward the patient. I considered this a serendip-
itous finding whose implications for research, training, and practice I
have been trying to explore ever since. (p. 437)
Any review of Strupp’s major accomplishments requires noting that
even his early research was characterized by rigorous scientific methods and
thinking—and at a time when few therapy research studies existed and when
most of them exhibited weak designs. Further, Strupp knew that it was crucial
to determine if psychotherapy can work: Does it potentiate more rapid and/or
more extensive benefits than the simple passage of time or informal, naturally
occurring sources of help, such as caring, wise friends? He also viewed evidence
that therapy can work as preliminary knowledge for both practice and science.
If therapies work, then the next main practice-relevant challenge is to dis-
cover why and how they work: Do they work for theoretically posited reasons?
Knowledge of mechanisms will enable practitioners to conduct treatments
systematically and efficiently. Vanderbilt I was among Strupp’s contributions
to a fundamental mechanism question of his, and contemporary, times.
Frank’s Common Factors Model and Vanderbilt I
Jerome Frank (1961, 1971) proffered his now classic common factors
model of how psychotherapies work in the early 1960s. The model partially
explained surprising but recurrent, then and now, findings of few if any statis-
tically significant differences between the outcomes of theoretically different
forms of psychotherapy. (More recent evidence indicates that the same often is
true for psychotherapy vs. medication.) The common factors model logically
attributes equivalent outcomes to variables that must be common to, that is,
shared by, different therapy approaches rather than to their unique, theory-
driven specific techniques. (Frank was aware of an alternative explanation:
Outcome measurement methods could be a key cause of no difference findings.)
Frank’s model, also cast as “nonspecific vs. specific factors,” became a
preoccupation for Strupp during groundbreaking NIMH-funded projects on
which he and Allen Bergin collaborated. One fruit of their effort was a dili-
gently crafted set of research questions and proposed experiments to answer
them. The questions and experiments appear in Changing Frontiers in the Sci-
ence of Psychotherapy (Bergin & Strupp, 1972), along with working papers in
which Strupp began to sketch out what became a classic experiment on non-

specific versus specific factors, Vanderbilt I. The very influential book empha-
sized the need for experimentally controlled, well-designed psychotherapy
research; Vanderbilt I later became a marker for the first of Strupp’s aforemen-
tioned two major conclusions.
Vanderbilt I was designed to test hypothesized added contributions to
outcomes of specific techniques that professional therapists are trained to use,
beyond benefits that might be potentiated by nonspecific factors such as a
confiding relationship with a trustworthy person who possesses socially sanc-
tioned credentials (credentials such as those of professional therapists). Male
college students who had clinically significant problems with depression,
anxiety, and shyness were randomly assigned to receive up to 25 sessions
of “therapy” twice a week from either professional psychotherapists or col-
lege professors who were reputed to be sought out by students for advice.
Two experimental control conditions were included: minimal contact and
waiting-list. No difference was found between the outcomes of professional
therapists and college professors (Strupp & Hadley, 1979), another finding of
the times that belied widespread assumptions.2
Within the next 10 years, Strupp concluded that the dichotomous con-
ceptualization of nonspecific versus specific factors itself was misguided—“a
pseudo problem that is not amenable to solution”—as a general model of the
mechanisms of action of psychotherapy (Strupp, 1995, p. 70). He advised that
it be abandoned. He came to believe that any curative effects of specific tech-
niques could not be isolated from qualities of the relationship between patient
and therapist in which techniques necessarily are embedded (Butler & Strupp,
1986; Strupp, 1995). He also sought to “move beyond simple notions of thera-
pist warmth and genuineness to describe more precisely the important aspects
of the therapist’s personal contribution to the therapeutic process” (Strupp,
Butler & Rosser, 1988, p. 693). Strupp’s final conclusion was that a theory of
therapeutic action that guided one of his major studies was an unproductive
heuristic to (a) frame experimental investigation of how psychotherapies work,
(b) strengthen psychotherapy as a generic treatment modality, or (c) guide clin-
ical thinking. He searched elsewhere and differently after Vanderbilt I.
Vanderbilt I Toward Vanderbilt II: Process–Outcome Studies, Varieties

of Scientific Method, Scientific Teamwork, and Negative Effects
The period after Vanderbilt I’s launch was filled with intensive process–
outcome studies (e.g., Gomes-Schwartz, 1978) and innovative research. For
2Strupp (1993; Strupp & Hadley, 1979) knew that the finding could be challenged due to the semiana-
logue nature of the sample, which consisted of randomly selected male undergraduate students recruited
by mail, many of whom were not independently seeking treatment. The limitation contributed to the
Vanderbilt II design in which treated adults were recruited by advertisement for low-cost therapy.
HANS STRUPP 57
example, Strupp, in the scientific tradition of systematically exploring data to
better understand surprising monothetic (aggregated group level) findings
and develop new hypotheses, conducted a series of post hoc, within-therapist,
case study comparisons of four Vanderbilt I therapists’ good- and poor-outcome
patients (e.g., Strupp, 1980). He concluded that patient characteristics and
also weaknesses in some therapists’ responses to interpersonally challenging
patient features contributed to poorer outcomes. Additionally, Strupp and his
research team surveyed relevant experts’ views on the critical but neglected,
then and now, topic of potential negative effects of psychotherapy (Strupp,
Hadley, & Gomes-Schwartz, 1977). The team also developed an observer-
rated process measure to identify predictors and potential causes of negative
outcomes (Suh, Strupp & O’Malley, 1986).
Research of the foregoing type helped solidify Hans’s conclusion that
the common factors model, which supported the ongoing nonspecific vs. spe-
cific factors debate, was fatally flawed. The work also paved the way to both
Vanderbilt II and to what ultimately became his aforementioned second
major conclusion.
Vanderbilt II: The Therapist’s Contribution, “Difficult” Patients,

and Toward Advances in Therapist Training
Vanderbilt II was designed to determine (a) if experienced therapists

could be trained to use intervention principles and techniques that were
specifically developed to better manage problematic, albeit frequent, inter-
personal processes in therapy sessions, and (b) if (a) was possible, whether
outcomes were better after the training. The centerpiece of Vanderbilt II was
a form of psychodynamically oriented psychotherapy that Strupp developed
with Jeffrey Binder, time-limited dynamic psychotherapy (TLDP; Strupp &
Binder, 1984). TLDP reflects the enduring impact of both Freud and Sullivan
on Strupp’s clinical understanding and research. Importantly, it also merged
nonspecific “relationship factors” and specific technique by “stress[ing] the
careful monitoring, exploration, and use of the therapeutic relationship as a
technical strategy in its own right” (Strupp, 1993, p. 432).
A key aim of TLDP was to help therapists successfully avoid or other-
wise manage limits to therapeutic progress potentially created by their nega-
tive attitudes and behaviors toward patients. TLDP also was intended to
extend the reach of therapists to patients often referred to as “difficult” and
“resistant.” Strupp realized that they were most likely in need of something
that professional, highly trained psychotherapists should be able to provide,
rather than patients who, according to decades of outcome findings, improve
no matter what form of therapy or placebo treatment they receive.

Observations from therapist training and supervision session material
and other Vanderbilt II data revealed “the pronounced inability of therapists
to avoid countertherapeutic processes with difficult patients” (Henry &
Strupp, 1992, p. 440), even though pre- to post- TDLP training differences
were obtained. Concern about potential countertherapeutic impacts of ther-
apists’ negative reactions to patients also was supported by process–outcome
analyses of Vanderbilt I data that suggested that even small amounts of ther-
apist blame and criticism were associated with poor outcome (Henry, Schacht,
& Strupp, 1986). A next step that Strupp deemed essential was to
develop training programs that are aimed at imparting fundamental inter-
personal skills as a point of departure for other forms of training. . . .
By developing new instructional approaches, we hope to narrow the gap
between basic psychotherapy research and its application to clinical
practice and training. (Henry & Strupp, 1992, p. 441)
The last sentence describes an unrealized goal and also a master’s insight
on a productive focus for contemporary psychotherapy research. Strupp’s guid-
ing suggestion after career-long investigation of the therapist’s contribution
was to refocus attention on training—a pivotal activity that remained mostly
unstudied in the era when he completed his work.
CONCLUSION
Hans Strupp’s later writings suggest that his strongest recommendation

to contemporary and future researchers is to attend to the complexity of man-
aging the therapeutic relationship and to the training of therapists. Both are
key to meeting the ongoing practice-relevant challenge to extend the effi-
cacy, effectiveness, and efficiency of psychotherapies as routinely provided.
Notably, Strupp also left the field with an explicit challenge to a currently
prominent view that nonspecific (common) relationship factors are the pri-
mary agent of psychotherapeutic change.
Strupp indeed concluded that qualities of the relationship between
therapist and patient are core determinants of therapeutic action. However,
he added two crucial caveats: (a) that one of the most “common” features of
therapy relationships is problematic interpersonal processes, and (b) that
such processes often are either cued or maintained by the therapist. Based on
findings and clinical observations that support (a) and (b), Strupp came to
strongly advocate research on developing therapist training methods that will
enable therapists to manage well the typical and ubiquitous traps and snags
of therapy relationships. Such developments are needed, Strupp would argue,
HANS STRUPP 59
because most psychotherapists’ best intentions and natural relationship skills
are inadequate to optimally serve individuals who stand most to benefit from
what psychotherapy, as a unique treatment modality, might offer.
REFERENCES
Bein, E., Anderson, T., Strupp, H. H., Henry, W. P., Schacht, T. E., Binder, J. L.,
& Butler, S. (2000). The effects of training in time-limited dynamic psycho-
therapy: Changes in therapeutic outcome. Psychotherapy Research, 10, 119–132.
doi:10.1080/713663669
Bergin, A. E. (2007). Hans H. Strupp (1921–2006). American Psychologist, 62, 249.
doi:10.1037/0003-066X.62.3.249
Bergin, A. E., & Strupp, H. H. (1972). Changing frontiers in the science of psycho-
therapy. Chicago, IL: Aldine-Atherton.
Butler, S. F., & Strupp, H. H. (1986). “Specific” and “nonspecific” factors in psycho-
therapy: A problematic paradigm for psychotherapy research. Psychotherapy, 23,
30–40. doi:10.1037/h0085590
Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy.
Baltimore, MD: Johns Hopkins Press.
Frank, J. D. (1971). Therapeutic factors in psychotherapy. American Journal of Psycho-
therapy, 25, 350–361.
Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends in psycho-
dynamic, humanistic, and behavioral practice. New York, NY: Springer.
Gomes-Schwartz, B. (1978). Effective ingredients in psychotherapy: Prediction of
outcome from process variables. Journal of Consulting and Clinical Psychology, 46,
1023–1035. doi:10.1037/0022-006X.46.5.1023
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1986). Structural analysis of social
behavior: Application to a study of interpersonal process in differential psycho-
therapeutic outcome. Journal of Consulting and Clinical Psychology, 54, 27–31.
doi:10.1037/0022-006X.54.1.27
Henry, W. P., & Strupp, H. H. (1992). The Vanderbilt Center for Psychotherapy
Research. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change
(pp. 436–442). Washington, DC: American Psychological Association.
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993).
Effects of training in Time-Limited Dynamic Psychotherapy: Changes in
therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434–440.
doi:10.1037/0022-006X.61.3.434
Strupp, H. H. (1955). An objective comparison of Rogerian and psychoanalytic tech-
niques. Journal of Consulting Psychology, 19, 1–7. doi:10.1037/h0045910
Strupp, H. H. (1973). On the basic ingredients of psychotherapy. Journal of Consult-
ing and Clinical Psychology, 41, 1–8. doi:10.1037/h0035619

Strupp, H. H. (1976a). Clinical psychology, irrationalism, and the erosion of excel-
lence. American Psychologist, 31, 561–571. doi:10.1037/0003-066X.31.8.561
Strupp, H. H. (1976b). Some critical comments on the future of psychoanalystic
therapy. Bulletin of the Menninger Clinic, 40, 238–247.
Strupp, H. H. (1977). A reformulation of the dynamics of the therapist’s contribu-
tion. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook
of research (pp. 1–22). Oxford, England: Pergamon Press.
Strupp, H. H. (1980). Success and failure in time-limited psychotherapy: A system-
atic comparison of two cases (Comparison 1). Archives of General Psychiatry, 37,
595–603.
Strupp, H. H. (1989). Psychotherapy: Can the practitioner learn from the researcher?
Strupp, H. H. (1993). The Vanderbilt psychotherapy studies: Synopsis. Journal of
Consulting and Clinical Psychology, 61, 431–433. doi:10.1037/0022-006X.61.3.431
Strupp, H. H. (1995). The psychotherapist’s skills revisited. Clinical Psychology: Science
and Practice, 2, 70–74.
Strupp, H. H. (n.d., circa 1988–2003). Unpublished manuscript.
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-
limited dynamic psychotherapy. New York, NY: Basic Books.
Strupp, H. H., Butler, S. F., & Rosser, C. L. (1988). Training in psychodynamic
psychotherapy. Journal of Consulting and Clinical Psychology, 56, 689–695.
doi:10.1037/0022-006X.56.5.689
Strupp, H. H., & Hadley, S. W. (1977). A tripartite model of mental health and ther-
apeutic outcomes with special reference to negative effects in psychotherapy.
Strupp, H. H., & Hadley, S. W. (1979). Specific vs. nonspecific factors in psychother-
apy: A controlled outcome study. Archives of General Psychiatry, 36, 1125–1136.
Strupp, H. H., Hadley, S. W., & Gomes-Schwartz, B. (1977). Psychotherapy for better
or worse: the problem of negative effects. New York, NY: Jason Aronson.
Suh, C. S., Strupp, H. H., & O’Malley, S. S. (1986). The Vanderbilt process measures:
The Psychotherapy Process Scale (VPPS) and the Negative Indicators Scale
(VNIS). In L. S. Greenberg & William M. Pinsof (Eds.), The psychotherapeutic
process: A research handbook (pp. 285–323). New York, NY: Guilford Press.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton.
HANS STRUPP 61
6
AARON T. BECK:
THE COGNITIVE REVOLUTION
IN THEORY AND THERAPY
STEVEN D. HOLLON
Aaron T. Beck is one of the leading clinical theorists of the last half
century. Coming of age at a time when dynamic theory was monolithic and
psychoanalysis the dominant method of treatment, he began his career by
seeking to confirm the primacy of unconscious motivations and ended up for-
mulating a theory of disorder that emphasized the role of inaccurate beliefs
and errors in thinking that were largely accessible to conscious introspection.
This novel cognitive theory led him to formulate principles of change that he
codified into a cognitive therapy that has become one of the most widely
practiced and best empirically supported interventions in the field today
(DeRubeis & Crits-Christoph, 1998). Beck has been the recipient of numerous
honors and is the only psychiatrist to have received research awards from the
American Psychological Association, the American Psychological Society, the
American Psychiatric Association, and the Institute of Medicine. He has
lectured throughout the world and was named one of the most influential psy-
chotherapists of all time by the American Psychologist (July 1989). Perhaps the
capstone of his career came when he received the Lasker Award, the nation’s
most prestigious medical prize (New York Times, September 17, 2006). In
announcing the award, Dr. Joseph L. Goldstein, the chairman of the Lasker
63
jury, called cognitive therapy “one of the most important advances—if not
the most important advance—in the treatment of mental diseases in the last
50 years.”
MAJOR CONTRIBUTIONS
Beck was trained in the psychodynamic model (like most psychiatrists

in the middle part of the last century) and embarked on an ambitious program
of research designed to test Freud’s notion that depression was a consequence
of unconscious anger directed against the self. In a series of experimental and
clinical studies, he found little evidence of the retroflected anger posited by
dynamic theory in the behavioral performance of his depressed patients or in
their dreams and free associations; what he found instead were consistent
themes of loss and personal failing. Rather than letting existing theories drive
his interpretations, he proposed a major reformulation that held that the core
problem in depression was not a product of unconscious drives and defenses
but, rather, the consequence of unduly negative beliefs and biased informa-
tion processing. In so doing he emphasized the causal role of one class of
symptoms of depression, a causal role that had been largely overlooked by the
major theoretical perspectives of the day.
In retrospect, it is easy to forget just how revolutionary this perspective
was or how controversial it proved to be. Psychodynamic theory dating from
Freud held that the causes of depression and other types of psychopathology
lay in unconscious motivations that could not be directly addressed without
triggering defenses in the patient that led them to resist efforts at change and
required, instead, years of careful and indirect exploration. Conversely,
behavior theory, its major competitor at the time, held that psychopathology
was a consequence of outside forces and could best be resolved by reordering
the external environment. Neither put much stock in the notion that the
things a patient believed, what he or she thought or expected, played a role
in the generation of distress and problems in coping. Beck’s cognitive refor-
mulation of psychopathology was truly revolutionary, and his cognitive the-
ory of change paved the way for some of the most efficacious treatments of
the modern era. It also was actively resisted at the time, and the larger psy-
chodynamic community regarded his views as heretical at best.
Beck’s monograph on depression, published in 1967, summarized this
work and became a classic in the field. In it he proposed that depression was in
part a consequence of a systematic tendency to perceive things in a negative
and biased fashion. He introduced his concept of the negative cognitive triad—
negative views about the self, the world, and the future—and explicated the
role of schema, clusters of beliefs, and proclivities with respect to information
64 STEVEN D. HOLLON
processing that serve to warp the way that information is processed in the direc-
tion of existing beliefs. He also introduced the rudiments of an approach to
treatment in which he laid out basic strategies for teaching patients how to
explore the accuracy of their own beliefs and how to protect themselves from
the biasing effects of schema-driven processing. In so doing, he drew heavily on
recent advances in cognitive psychology that emphasized the way in which
existing beliefs could bias information processing and developed a sophisticated
set of clinical procedures to offset those proclivities.
By the early 1970s he had developed a coherent approach to treatment
based on the principles that he called cognitive therapy. At this time, there was
no evidence that any psychosocial intervention was as efficacious as medications
in the treatment of depression or even superior to pill-placebo controls. Before
the end of the decade, he and colleagues at the University of Pennsylvania pub-
lished a randomized controlled trial in which cognitive therapy outperformed
medications, the current standard of treatment (Rush, Beck, Kovacs, & Hollon,
1977). Patients in that trial were not only as likely to respond to cognitive
therapy as to medications, but they also were considerably more likely to stay
well after treatment termination. This was not only the first time that any psy-
chosocial treatment had held its own with medication in the treatment of
depression but also the first clear evidence of an enduring effect for psychother-
apy, something that had long been claimed but never before demonstrated.
Thirty years of subsequent research have fully supported these early
claims. Cognitive therapy is now widely recognized as an empirically sup-
ported psychosocial treatment for depression, and the proposition that it has
enduring effects not found for medications is well supported in the literature
(Hollon, Stewart, & Strunk, 2006). Moreover, evidence of its efficacy is not
limited to depression; he has taken the lead in extending the approach to
other disorders and many others have followed. There now is clear evidence
for its efficacy and enduring effects for nearly all of the nonpsychotic dis-
orders (including panic and the anxiety disorders, somatic disorders such as
hypochondriasis, eating disorders such as anorexia and bulimia, substance
abuse and addiction, marital distress, and a variety of both internalizing and
externalizing childhood disorders), as well as emerging work in the personal-
ity disorders (including borderline personality disorder and antisocial person-
ality) and the psychoses (including bipolar disorder and the schizophrenias;
Butler, Chapman, Forman, & Beck, 2006).
Beck has been committed to the empirical evaluation of his theories
and the therapy that developed from them. He viewed his theories as provi-
sional only and sought to subject them to empirical disconfirmation in as
timely a manner as possible. His empirical studies have consistently pitted his
preferred intervention against the best existing treatments in the field, and
he has shown a keen awareness of the need to balance investigator allegiance
AARON T. BECK 65
to be sure that each modality tested has a fair chance at success. The quality
and impartiality of these investigations have contributed greatly to his impact
on the field, and the ease with which they have been replicated speaks to the
generalizability of the approach. Cognitive theory has evolved over the years,
and cognitive therapy has been revised on the basis of both experimental
findings and clinical insights, allowing it to be generalized to numerous other
disorders across a variety of clinical situations. There is even evidence that
cognitive therapy can be taught to persons at risk in the service of preventing
the emergence of subsequent distress. His commitment to the principles of sci-
ence and his willingness to subject his beliefs to potential disconfirmation have
contributed both to shaping the approach and to the success it has enjoyed.
EARLY BEGINNINGS
Aaron T. Beck was the youngest of five children of parents who both emi-
grated from Russia (see Weishaar, 1993, for a detailed description of his early
life). His father was a printer by trade and an intellectual by nature who was a
strong supporter of socialistic principles. His mother was a strong-willed woman
who gave up her dream of going to medical school to care for her younger sib-
lings after the untimely death of her own mother. There are indications that
his mother became depressed herself following the loss of a daughter during the
great influenza epidemic of 1919 and that her distress remitted only after the
birth of her youngest son, Aaron (perhaps his first successful cure).
Beck himself nearly died at age seven after a broken bone in his arm
became infected and he developed septicemia, an infection of the blood that
was nearly always fatal at that time. The surgery itself was traumatic. He was
separated from his mother without warning and put under the knife before
the anesthetic had taken effect. This experience led to fears of abandonment
and health-related phobias that he only mastered later in life by thinking
through their cognitive antecedents and testing their accuracy by exposing
himself to the situations that he feared (one of his reasons for later going into
medicine). Moreover, he missed so much time from school that he was held
back a grade, leading him to think of himself as “dumb and stupid,” but he
sought help from his older brothers and came to excel in school, leading him
to believe that he could overcome misfortune through hard work and use a
“never say die” attitude to turn “a disadvantage adversity into an advantage”
(Weishaar, 1993, p. 10). In many respects, In many respects, the seeds of his
later theoretical innovations were sown by his own early life experiences;
his initial response to these traumatic life events was to develop exagger-
ated beliefs (reasonable under the circumstances) that overestimated the risk
inherent in health-related or educational situations and that underestimated
66 STEVEN D. HOLLON
his own capacity to cope—beliefs he overcame by thinking them through and
forcing himself to engage in what he feared, to test their accuracy.
He graduated first in his high school class and followed his older broth-
ers to Brown University. Although he majored in English and political sci-
ence, he decided to pursue a career in medicine, only to be discouraged by a
professor from applying to medical school because of the anti-Semitism of the
time. He pursued extra premed course work nonetheless and graduated magna
cum laude in 1942, having been elected to Phi Beta Kappa. He applied to only
three or four medical schools and was admitted to Yale, in part because he
shared an interest in the works of Aldous Huxley with the professor of pedi-
atrics who conducted his admissions interview.
He was not originally interested in psychiatry or psychotherapy and
embarked on a residency in neurology after completing medical school. He
was attracted to neurology by its disciplined diagnostic procedures and its
capacity to pinpoint the precise location of lesions in the nervous system on
the basis of careful clinical observation. It was during the course of a manda-
tory 6-month rotation in psychiatry that he became fascinated with its sub-
ject matter and with psychoanalysis in particular, which he thought would
reveal the inner workings of the human mind. He completed a 2-year fellow-
ship at Austin Riggs Center in Stockbridge Massachusetts (supervised by Erik
Erikson) before volunteering to serve at the Valley Forge General Hospital,
an army hospital near Philadelphia. He was board certified in psychiatry in
1953 and became an instructor in psychiatry at the University of Pennsylva-
nia the following year. He graduated from the Philadelphia Psychoanalytic
Institute in 1958 and became an assistant professor at Penn the following
year, receiving his first research grant (to study dreams) in the process.
It was during his internship that he met his wife, Phyllis. She was a jour-
nalist by training who wrote for Time magazine and the Berkshire Eagle (Pitts-
field, MA) before taking a master’s degree in social work and ultimately going
on to law school while raising four children. She enjoyed a long and success-
ful career in the law and became the first woman to be elected a superior court
judge in Pennsylvania. Retired from the bench, she is now the chief counsel
for the Barnes Foundation.
ACCOMPLISHMENTS
From the Exploration of Dreams to the Identification of Beliefs
Although Beck became deeply interested in psychodynamic principles, he

initially approached them with some ambivalence. He had always had a rebel-
lious streak intellectually, and he found that his pragmatic nature sometimes
AARON T. BECK 67
made psychoanalytic principles seem counterintuitive. Nonetheless, he decided
to suspend his initial disbelief and threw himself into his analysis. He remained
troubled by its lack of a scientific basis and came to believe that empirical evi-
dence was necessary to convince the hard-headed skeptic. He came to view psy-
chological research as a way to validate psychoanalytic concepts and make them
acceptable to the scientific community.
He decided to focus on depression, the most frequent disorder in his
practice, and began a series of studies designed to show that depression was a
consequence of unconscious rage against others that became repressed and
turned against the self. Adhering to the notion that dreams represented the
“royal road to the unconscious,” he began to study the dreams of his depressed
patients and to compare them with the dreams of patients who were not
depressed. What he found, to his dismay, was that the dreams of his depressed
patients actually contained less hostility than those of his nondepressed con-
trols. What they did contain were the same themes of rejection and failure
that patients expressed in their waking conscious verbalizations. He consid-
ered other more complex interpretations that preserved the primacy of the
unconscious (none supported by the data) before coming to what he termed
the “simple-minded hypothesis” that the negative way in which patients see
themselves is actually the basic process, rather than the derivative of uncon-
scious forces (Beck, 2006, p. 1139). The essence of this formulation was that
there was no need to go deeper; a model based on his patients’ internal rep-
resentations of themselves, their experiences, and their future could account
for both their dreams and their symptoms.
Experimental work was crucial to this paradigmatic shift. In an effort to
test between the competing interpretations, Beck and colleagues put depressed
and nondepressed patients in controlled performance situations and manipu-
lated their success or failure. In opposition to psychodynamic theory, which
would have predicted a masochistic worsening of mood in reaction to posi-
tive feedback, what he found is that both the mood and performance of his
depressed patients improved when they experienced instances of success
(Loeb, Beck, & Diggory, 1971; Loeb, Feshbach, Beck, & Wolf, 1964). These
studies not only contradicted predictions generated from psychodynamic
theory but also pointed to the kind of clear and pragmatic strategies that could
be used clinically to disconfirm the patients’ negative beliefs.
Over the next several years, he began to experiment with helping
patients recognize their own internal dialogue (often in the form of fleeting
negative “automatic thoughts” that consisted of demeaning self-evaluations
and distorted misinterpretations of innocuous events) and found that he could
guide them to examine the validity of their own beliefs through a process of
Socratic questioning and the use of behavioral experiments. He described his
approach, which he called cognitive therapy, in a series of case reports that
68 STEVEN D. HOLLON
he presented at the Association for the Advancement of Behavior Therapy
(Beck, 1970). John Rush, one of his residents at the time, encouraged him to
conduct a randomized controlled trial that found that cognitive therapy was
both superior to and longer lasting than medication (Rush et al., 1977).
Role of Beliefs in the Etiology and Treatment of Psychopathology
While Beck was developing his cognitive theory and therapy of depres-
sion, he also began to ask whether cognitive processes played a role in other
disorders and whether he could identify a specific profile of distortions and
beliefs that was associated with each. In order to carry out this work, he orga-
nized a clinic, called first the Mood Clinic and later the Center for Cognitive
Therapy, that enabled him to study individuals with a variety of disorders and
to use their clinical materials to probe the nature of their distress and to
explore methods of intervention with his colleagues and his students. His
treatise on the Cognitive Therapy of the Emotional Disorders provided an early
road map to this approach (Beck, 1976). The basic strategy that he followed
was to collect a large number of clinical observations for a specific disorder
(focusing on the automatic thoughts and underlying beliefs), derive a formu-
lation for the particular disorder, and devise inventories and rating scales to
measure the specific clinical variables. Then, on the basis of the cognitive
profile, he would adapt the generic cognitive model to fit the specific charac-
teristics of the disorder.
He and his colleagues and students would then generate clinical inter-
ventions based on these principles and observations that were collated into
treatment manuals that could be used in randomized controlled intervention
trials. This basic research strategy, first developed in his work on depression
(Beck, Rush, Shaw, & Emery, 1979), was subsequently applied to the study
and treatment of panic and the anxiety disorders (Beck, Emery, & Greenberg,
1985), personality disorders (Beck, Freeman, & Associates, 1990), and sub-
stance abuse (Beck, Wright, Newman, & Liese, 1993).
Beck has had a long-standing interest in suicide and its prevention.
Early in his career he and his colleagues constructed a new classification sys-
tem and developed instruments to validate it (Beck, Resnik, & Lettieri,
1974). He found, for example, that persons with elevated levels of hopeless-
ness were at significant risk of ultimate suicide and that predictors of sub-
sequent risk among suicide attempters included expressions of regret over the
failure of their attempt(s) and increasing intensity of ideation across attempts
(Beck, Morris, & Beck, 1974). This work culminated in the development of
a brief cognitive therapy for suicide that has been shown to cut the frequency
of subsequent attempts in half among high-risk patients with a recent history
of attempts (Brown et al., 2005).
AARON T. BECK 69
During the 1970s and 1980s, Beck made a series of extended visits to
Britain and particularly Oxford University, where the chairman of psychiatry,
Michael Gelder, was strongly supportive of the cognitive therapy approach.
There he met with John Teasdale and Mark Williams (joined by Zindel Segal
of Toronto) who added meditation to develop a mindfulness-based approach
to cognitive therapy. He had a strong influence on David M. Clark and Paul
Salkovskis (later joined by Anke Ehlers), who used the systematic approach
he applied to depression to adapt cognitive therapy to the treatment of a vari-
ety of anxiety disorders, including panic, social phobia, hypochondrias, post-
traumatic stress disorder, and obsessive–compulsive disorder, among others.
This latter group (who subsequently moved to the Institute of Psychiatry in
London) has done some of the most elegant translational work in the field
today. Dominic Lam, another former trainee, adapted the approach to the pre-
vention of recurrence in bipolar disorder, and Christopher Fairburn at Oxford
and Kelly Bemis Vitousek in Hawaii have been strongly influenced by cogni-
tive therapy in their respective work with eating disorders. David Kingdon and
Douglas Turkington in England applied the basic framework to successfully
adapt cognitive therapy to the treatment of residual symptoms in schizophre-
nia (Kingdon & Turkington, 1994). Other research groups in the United
Kingdom have found similarly promising results in the treatment of both acute
and chronic patients. This work has been slow to be adopted in the United
States (where clinical lore has long presumed that you cannot reason with
someone who is psychotic) but is beginning to make its way across the Atlantic
(Beck & Rector, 2005). In addition to his work on mindfulness, Zindel Segal
in Toronto has investigated the neural processes underlying change in treat-
ment in cognitive therapy versus medications, and David A. Clark in Nova
Scotia has explored the cognitive process underpinning depression and related
anxiety disorders. Much of the work in the United States has focused on
depression (including that by Robert J. DeRubeis and Steven D. Hollon),
and Martin Seligman at the University of Pennsylvania and Judy Garber at
Vanderbilt have each investigated the role of cognitive interventions in the
prevention of depression in at-risk children and adolescents.
Other Contributions
Beck was a driving force in establishing the journal Cognitive Therapy

and Research. He served on its executive board for many years and published
his classic comparison of cognitive therapy versus medication in the treat-
ment of depression in its inaugural issue (Rush et al., 1977). He is an active
participant in and regularly attends the Association for Behavior and Cogni-
tive Therapies (ABCT), the Society for Psychopathology Research, and the
Society for Psychotherapy Research. He was the driving force in establishing
70 STEVEN D. HOLLON
the Academy of Cognitive Therapy, an organization that certifies compe-
tence in cognitive therapy based on actual tape ratings, and has founded both
the Center for Cognitive Therapy at the University of Pennsylvania and the
Beck Institute in nearby Bala Cynwyd.
Dr. Beck has authored over 450 articles in peer-reviewed journals and
17 books and treatment manuals. Many of these publications (on depression,
anxiety, personality disorders, and other clinical problems) have become clas-
sics in the field (e.g., Beck, 1967, 1976; Beck et al., 1979, 1985; Beck, Free-
man, & Associates, 1990). In addition, Beck and his colleagues and students
have written a number of treaties and self-help manuals for the public (Beck,
1988; Burns, 1980; Greenberger & Padesky, 1995). Beck has developed a num-
ber of major self-report and clinical rating instruments. The Beck Depression
Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is the most
widely used self-report instrument in the field and the Hopelessness Scale
(Beck, Weissman, Lester, & Trexler, 1974) has been shown to be a better pre-
dictor of risk of suicide than depression (Beck, Brown, Berchick, Stewart, &
Steer, 1990). The Dysfunctional Attitudes Scale is widely used as a measure of
beliefs and attitudes conferring risk for depression (Weissman & Beck, 1978)
and the Cognitive Therapy Scale is widely used as a measure of competence
with cognitive therapy (Young & Beck, 1980). He also developed the Suicide
Intent Scale (Beck, Morris, & Beck, 1974) and the Scale for Suicide Ideation
for work in the assessment of suicide and the prediction of risk (Beck, Brown,
& Steer, 1997).
INFLUENCES
Beck was strongly influenced by Freudian theory in his early professional

years, although he was restless and dissatisfied with its lack of scientific basis
(Weishaar, 1993). He longed to provide the kind of empirical evidence neces-
sary to convince a hard-headed scientist, and he numbered Seymour Feshbach
and Marvin Hurvich, experimental psychologists on faculty in the Depart-
ment of Psychology at Penn, among his early collaborators. His personal ana-
lyst, Leon Saul, who wrote about conscious processes, strongly influenced his
interest in dream research. He also was greatly influenced by the writings of
George Kelly and Albert Ellis, who were starting to challenge the dominance
of psychodynamic thought in psychotherapy and were subsequently joined by
colleagues like Donald Meichenbaum and Michael Mahoney, who intro-
duced cognitive principles into conventional behavior therapy. Beck has
mentored a number of students and junior collaborators, many of whom have
gone on to distinguish themselves in independent careers. These include
A. John Rush, one of the preeminent biological psychiatrists in the field
AARON T. BECK 71
today; Marika Kovacs, a noted developmental psychopathologist who does
longitudinal research on the development of risk for depression in children;
and David M. Clark, one of the most innovative and highly regarded anx-
iety researchers of his generation. Others greatly influenced by Beck include
his daughter, Judith Beck (a major theorist in her own right), David Burns,
Robert J. DeRubeis, Arthur Freeman, Steven D. Hollon, Christine Padesky,
Jackie Persons, Brian F. Shaw, Kelly Bemis Vitousek, and Jeffrey Young, among
others, three of whom have gone on themselves to become presidents of ABCT.
CONCLUSION
Aaron T. Beck has had a major impact on what the field thinks about
psychopathology and the nature of treatment for the mental disorders. He is
the architect of one of the most widely used and efficacious psychotherapies
in the field today. His work has been prodigious and his influence profound,
in part because of his insistence on subjecting his ideas to the stiffest possible
empirical tests. His theoretical notions about the role of cognition in the eti-
ology and maintenance of psychopathology have revolutionized the field, and
the clinical innovations he developed have coalesced into one of the most
widely practiced and best empirically supported interventions of the day. He
is truly a giant in the field.
REFERENCES
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New

York, NY: Hoeber.
Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy.
Behavior Therapy, 1, 184–200. doi:10.1016/S0005-7894(70)80030-2
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY:
Meridian.
Beck, A. T. (1988). Love is never enough. New York, NY: Harper & Row.
Beck, A. T. (2006). How an anomalous finding led to a new system of psychotherapy.
Nature Medicine, 12, 1139–1141. doi:10.1038/nm1006-1139
Beck, A. T., Brown, G. K., & Steer, R. A. (1997). Psychometric characteristics of the
Scale for Suicide Ideation with psychiatric outpatients. Behaviour Research and
Therapy, 35, 1039–1046. doi:10.1016/S0005-7967(97)00073-9
Beck, A. T., Brown, G. K., Berchick, R. J., Stewart, B. L., & Steer, R. A. (1990).
Relationship between hopelessness and ultimate suicide: A replication with psy-
chiatric outpatients. American Journal of Psychiatry, 147, 190–195.
72 STEVEN D. HOLLON
Beck, A. T., Emery, G., & Greenberg, R. (1985). Anxiety disorders and phobias: A cog-
nitive perspective. New York, NY: Basic Books.
Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality dis-
orders. New York, NY: Guilford Press.
Beck, A. T., & Rector, N. (2005). Cognitive approaches to schizophrenia: Theory
and therapy. Annual Review of Clinical Psychology, 1, 577–606. doi:10.1146/
annurev.clinpsy.1.102803.144205
Beck, A. T., Resnik, H. L. P., & Lettieri, D. (1974). The prediction of suicide. Bowie,
MD: Charles Press.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). The cognitive therapy of
depression. New York, NY: Guilford Press.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An
inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.
Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of
pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology,
42, 861–865. doi:10.1037/h0037562
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy
of substance abuse. New York, NY: Guilford Press.
Beck, R. W., Morris, J. B., & Beck, A. T. (1974). Cross-validation of the Suicidal
Intent Scale. Psychological Reports, 34, 445–446.
Brown, G. K., Have, T. T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck,
A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A
randomized controlled trial. JAMA, 294, 563–570. doi:10.1001/jama.294.5.563
Burns, D. D. (1980). Feeling good: The new mood therapy. New York, NY: William
Morrow.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical
status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psy-
chology Review, 26, 17–31. doi:10.1016/j.cpr.2005.07.003
DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and
group psychological treatments for adult mental disorders. Journal of Consulting
and Clinical Psychology, 66, 37– 52. doi:10.1037/0022-006X.66.1.37
Greenberger, D., & Padesky, C. A. (1995). Mind over mood. New York, NY: Guilford
Press.
Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Cognitive behavior therapy has
enduring effects in the treatment of depression and anxiety. Annual Review of
Psychology, 57, 285–315. doi:10.1146/annurev.psych.57.102904.190044
Kingdon, D. G., & Turkington, D. (1994). Cognitive-behavioral therapy of schizophrenia.
New York, NY: Guilford Press.
Loeb, A., Beck, A. T., & Diggory, J. (1971). Differential effects of success and failure
on depressed and nondepressed patients. The Journal of Nervous and Mental
Disease, 152, 106–114. doi:10.1097/00005053-197102000-00003
AARON T. BECK 73
Loeb, A., Feshbach, S., Beck, A. T., & Wolf, A. (1964). Some effects of reward upon
the social perception and motivation of psychiatric patients varying in depression.
Journal of Abnormal and Social Psychology, 68, 609–616. doi:10.1037/h0044260
Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. (1977). Comparative efficacy of cog-
nitive therapy and pharmacotherapy in the treatment of depressed outpatients.
Cognitive Therapy and Research, 1(1), 17–37. doi:10.1007/BF01173502
Weishaar, M. E. (1993). Aaron T. Beck. Thousand Oaks, CA: Sage Publications.
Weissman, A. N., & Beck, A. T. (1978, November). Development and validation of the
dysfunctional attitude scale: A preliminary investigation. Paper presented at the
meeting of the American Educational Research Association, Toronto, Canada.
Young, J., & Beck, A. T. (1980). Cognitive Therapy Scale: Rating manual. Unpublished
manuscript, University of Pennsylvania, Philadelphia.
74 STEVEN D. HOLLON
II
DOES PSYCHOTHERAPY
WORK?
7
IRENE ELKIN: “THE DATA ARE
ALWAYS FRIENDLY”
KARLA MORAS AND M. TRACIE SHEA
Clinical psychologist Irene Elkin1 has had unique and profound influ-
ence on psychotherapy research since the early 1970s. Her career has shown
her to be a consummate scientist, possessing a keen intellect and fund of
knowledge, unassailable scientific integrity, and commitment to bringing the
best science possible to research on psychotherapy. Elkin’s achievements
also document her commitment to balancing the tension between conduct-
ing rigorous experimental science and preserving the essentially human
qualities of psychotherapy. Among her many contributions, Elkin is perhaps
best known for spearheading a study that had a paradigm-shifting impact
on the field during the last decades of the 20th century, the Treatment of
Depression Collaborative Research Program (TDCRP; e.g., Elkin, 1994;
Elkin et al., 1989, 1995; Parloff & Elkin, 1992) for the U.S. National Institute
of Mental Health (NIMH). The TDCRP demonstrated the feasibility of
several powerful scientific methods for use in psychotherapy outcome research.
It thereby helped set new methodological standards for the field—standards
that strengthened conclusions that could be drawn about a therapy’s potential
1Elkin published some of her work as Irene Waskow, using her former husband’s surname.
77
effects, its effects compared with those of other forms of therapy and also of
medication, and related practice-relevant questions. More broadly, Elkin has
brought conceptual and methodological clarity to many of the field’s key
questions.
MAJOR CONTRIBUTIONS
For this chapter, we organized Elkin’s major contributions to therapy

research into four main areas: conceptual and methodological clarity, increas-
ing the rigor of the field’s scientific standards and methods, promoting research
on mechanisms of change (psychotherapy process research), and generativity.
Elkin’s contributions reflect the relatively unique trajectory of her career. Most
of it was spent at NIMH, where her work focused on furthering the mental
health mission of the institute and using its resources to advance the field of
psychotherapy research. For example, early on she facilitated therapy research
by providing expert consultation to those seeking NIMH funding, organized
national conferences on key topics, and initiated and supported contracts in
areas of specific need or interest.
In 1978, Elkin’s main focus shifted dramatically when she took the
reins of the TDCRP as its NIMH coordinator. She remained at NIMH for
12 more years, seeing the TDCRP through to completion and the write-up
of major findings, before moving to academia as a tenured full professor at
the University of Chicago in its School of Social Service Administration
(SSA). There, Elkin revived the earliest phase of her career by pursuing
her own therapy research interests, particularly process-based studies. In
1996, she received an NIMH Research Scientist Award grant for such work.
She continued to examine crucial questions in therapy research (e.g., ther-
apist effects) with SSA graduate students and other colleagues (e.g., Elkin,
Falconnier, Martinovich, & Mahoney, 2006; Shaw et al., 1999) while teach-
ing therapy research seminars, mentoring SSA students, directing an NIMH-
funded training program in mental health services research for a number
of years, and serving as the field’s central resource for TDCRP data and
other inquiries.
Elkin’s enormous contributions have been recognized with many awards,
including the Administrator’s Award for Meritorious Achievement (1987)
from the U.S. Alcohol, Drug Abuse, and Mental Health Administration for
her work on the TDCRP; Research Career Award (1994) from the Society
for Psychotherapy Research, and the American Association of Applied and
Preventive Psychology’s Distinguished Contributions to Applied Research in
Psychology Award (1997).
78 MORAS AND SHEA

EARLY BEGINNINGS
Irene Elkin was born on December 27, 1933, in Milwaukee, Wisconsin.

She lived there with her parents and sister until 1951, when she moved to
Madison to start college at the University of Wisconsin (UW). Valedictorian
of her high school class, Elkin was the first in her family to complete college.
At the time it was rare for students from the poor neighborhood in which she
grew up to go to college, much less obtain a doctorate. After receiving a BS
in psychology from UW, Elkin moved on to Indiana University in Blooming-
ton, where she earned a master’s degree in psychology (1957). She then
returned to Madison and UW, where her husband was in graduate school. In
1960, Elkin received a PhD in clinical psychology from UW.
The two psychology departments in which Elkin completed her under-
graduate and graduate education were often referred to as “hotbeds of empiri-
cism.” They were “mainly experimentally oriented, with stress on asking
researchable questions about important aspects of human behavior” and “car-
rying out rigorous research with adequate statistical approaches to address
them” (Elkin, personal communication, October 22, 2007). She internalized
the scientific approach she learned. One of her career-long principles for ther-
apy research was to “adapt the rigorous research approach to the realities and
complexities of psychotherapy and [also to] the need to maintain the integrity
of the clinical subject matter” (Elkin, personal communication, October 22,
2007). As Elkin’s early UW colleague Eugene Gendlin recently observed at
a celebration in her honor: A defining feature is her passionate interest in
“the juncture of absolutely genuine research and absolutely genuine human
phenomena.”
How did Elkin choose psychotherapy research as a career focus? When
starting college, she wanted to become a social worker. A friend’s sister was a
social worker, and Elkin was moved by the idea that social work would enable
her to “do good things for people.” However, once in college, Elkin was swiftly
introduced to abnormal/clinical psychology by E. Earl Baughman, became
hooked on research, and decided to pursue psychology because it placed a
greater emphasis on research than did social work. As an undergraduate,
while assisting UW professor Horace A. Page, Elkin observed the process of
being able to ask an interesting question and then design and conduct a study
to answer it. The experience sparked an enduring enthusiasm for research.
Also formative was the work of the learning theorists, Miller and Dollard.
Elkin was drawn to learning theory and specifically to how learning theory
might elucidate the processes of therapy. Her dissertation, “Selective Rein-
forcement in a Therapy-Like Situation,” was a psychotherapy study that
also reflected the impact of learning theory on Elkin’s thinking. In the study,
IRENE ELKIN 79
published in the Journal of Consulting Psychology in 1962, she examined the
effects of the therapist’s behavior on the process of therapy, an enduring
theme in her research (e.g., Elkin, 1999; Elkin et al., 2006). While complet-
ing her PhD at UW, Elkin worked closely with Carl Rogers and Gendlin on
Rogers’s famed study of psychotherapy with patients with schizophrenia. She
identifies Rogers, Harry Stack Sullivan, and Miller and Dollard as major influ-
ences on her research career. Elkin’s career-long research mantra, “the data
are always friendly,” likely was adapted from a similar statement that has been
attributed to Rogers.
After graduate school, Elkin held a postdoctoral research fellowship at
the NIMH intramural Psychology Laboratory, under the sponsorship of David
Shakow. There she was exposed to a variety of psychotherapy approaches and
researchers, learning about various therapeutic strategies from Paul Bergman
and receiving training from Allen Dittmann in verbal and nonverbal emo-
tional expression. A central, enriching, and lifelong colleagueship also began
at the time: Elkin met Morris Parloff, then chief of the laboratory’s section on
personality, with whom she later worked closely on the conceptualization and
initiation of the TDCRP, and other shared contributions to therapy research.
In 1969, Elkin joined the Psychotherapy and Behavioral Intervention Sec-
tion, marking the start of her many years of influence on the field of therapy
research from NIMH.
ACCOMPLISHMENTS
Conceptual and Methodological Clarity
Elkin’s career at NIMH illustrates how effectively a person can help

advance a field by grasping its essential qualities and needs at a point in time,
and then using public resources to guide and seed it. The preceding is exem-
plified in Psychotherapy Change Measures: Report of the Clinical Research Branch
Outcome Measures Project (Waskow & Parloff, 1975). The book summarizes
the Outcome Measures Project that was launched by Elkin (then Waskow)
to improve the quality and impact of therapy outcome studies by provid-
ing reviews of various approaches to evaluating therapy outcome and by
encouraging investigators to adopt a standard battery of outcome measures
to include in their studies. A standard battery would allow direct, cross-
study comparison of results, thereby enabling psychotherapy researchers to
more quickly provide a cumulative body of knowledge on practice-relevant
questions.
Elkin’s conceptual and methodological clarity also contributed to the
unique strengths of the TDCRP design and methods. She fully comprehended
80 MORAS AND SHEA

the field’s primary practice-relevant questions at the time and also the scien-
tific and methodological hurdles it faced to answer them when, in the late
1970s, Parloff and she proposed to NIMH administrators that the institute
mount a therapy research study with the features of the TDCRP, unique to
psychotherapy research at the time: a relatively large-sample, collaborative
and multisite, controlled, comparative clinical trial design in which the ther-
apies to be tested were clearly articulated in manuals that described their stan-
dard implementation.
Elkin also ensured that the advances in conceptual and methodological
clarity that were a by-product of the TDCRP collaborators’ painstaking atten-
tion to, and dialogue about, the study’s scientific methods were made avail-
able to the entire field. For example, two articles elucidate core issues related
to designing and interpreting comparative studies of the effects of psychother-
apies and medication (Elkin, Pilkonis, Docherty, & Sotsky, 1988a, 1988b).
Twenty years later, both articles still qualify as highly recommended reading
for researchers and practitioners who want to deepen their understanding of
comparative psychotherapy and psychopharmacology outcome studies.
A premier example of the clarity that Elkin brought to practice-relevant
research questions is her analysis of the difficulties of distinguishing therapists’
unique qualities from therapeutic techniques and other elements of therapies
as possible effects on outcomes. Elkin’s (1999) important article on “dis-
entangling therapists from therapies” is a product of her career-long interest
in the therapist’s contribution to therapy processes and outcomes. It also serves
as an update on a fundamental hurdle still facing therapy research, particu-
larly if read in conjunction with Kiesler’s (1966) classic, early articulation of
conceptual and methodological issues in therapy research as it was typically
done over 40 years ago.
Enhancing the Field’s Scientific Standards and Methods
Through her work on the TDCRP, Elkin had a transformative impact on

methodological standards for psychotherapy research. In short, many of the
requirements currently taken for granted in designing and conducting psycho-
therapy outcome studies have become standards by virtue of the TDCRP. The
most far-reaching contributions of the TDCRP might not ultimately be its
substantive findings but, rather, its role in advancing psychotherapy research
methods and also creating the opportunity via archived TDCRP data for non-
TDCRP investigators to later examine additional questions about the process
and outcomes of psychotherapies.
The two main aims of the TDCRP were to determine the feasibility of
the multisite (collaborative) clinical trial design for psychotherapy research
and to examine the efficacy of two forms of brief psychotherapy (16 weeks)
IRENE ELKIN 81
for outpatient depression: cognitive therapy (Beck, Rush, Shaw & Emery,
1979) and interpersonal psychotherapy (Klerman, Weissman, Rounsaville,
& Chevron, 1984). A pharmacological treatment (imipramine) served as a
standard reference condition, and a pill placebo was included as a control for
imipramine, to determine if imipramine was a valid standard reference con-
dition in the study’s sample of depressed patients. The placebo also served as
control for the psychotherapies.
Elkin invested an enormous amount of time, energy, and passion in
every aspect of the TDCRP throughout the many years covering its planning,
implementation, and publication of findings. Her rigorous scientific standards
and meticulous approach were crucial for such a large-scale, highly visible,
and potentially influential—both on research and practice—study. At the
inception of the TDCRP, the multisite, randomized controlled comparative
clinical trial design had been widely used in psychopharmacology research but
not psychotherapy research. Applying the design to test the efficacy of psycho-
therapies introduced new challenges. For example, in contrast to psychophar-
macology studies, standardized delivery of psychotherapy could not be assumed.
Ensuring adequate delivery of the putative “active ingredient” is far more
complex in psychotherapy, requiring detailed articulation and assessment of
specific therapist interventions. Development of manualized therapies and
the assessment of therapist adherence to, and competence with, a specified
form of therapy had begun, but they were in an early stage when the TDCRP
was initiated. Elkin recognized the critical importance, for a comparative out-
come study’s internal validity, of being able to demonstrate that therapists
administered the treatments as defined by their developers (adherence) and
with an acceptable level of competency, and also to show that the treat-
ments compared were distinct in their delivery. Through contracts, Elkin
provided for the development and application of a reliable and comprehen-
sive observer-based measure of therapist adherence to the TDCRP treatments,
the Collaborative Study Psychotherapy Rating Scale (CSPRS; Hollon,
Waskow, Evans, & Lowry, 1984). The CSPRS quickly became regarded as
the “Cadillac” of such instruments. It was used to assess adherence to the
theoretically key interventions of each therapy tested in the TDCRP and
also to the clinical management component of the pharmacotherapy condi-
tions (Hill, O’Grady, & Elkin, 1992). The use of such scales is now standard
practice in the field.
One key aim of the TDCRP, to determine if the multisite clinical trial
design was feasible for psychotherapy research, yielded a clear answer: Yes.
Many such studies have been conducted since (e.g., Barlow, Gorman, Shear,
& Woods, 2000). Further, the main TDCRP outcome paper (Elkin et al.,
1989) alone has been cited more than 1,000 times to date, a sign of the study’s
huge impact. Although some controversy arose about interpretation of the
82 MORAS AND SHEA

main findings of the TDCRP (e.g., Elkin et al., 1989) and key others (e.g.,
Elkin et al., 1995), many of these findings have proved to be valuable and
influential for both practice and further research. With respect to treatment
effects, patients in all four conditions, including pill placebo plus clinical
management, improved significantly. Furthermore, none of three specific
treatments consistently differed significantly from the pill placebo condi-
tion in the main outcome analyses. Subsequent analyses yielded clinically
relevant “customization” of the preceding—surprising—outcome findings.
Pretreatment severity of depression and functional impairment were shown
to be important clinical indicators of treatments of choice: For more severely
depressed and functionally impaired patients, an antidepressant medication,
and to a lesser extent, interpersonal therapy, may be particularly effective. In
contrast, for less severely depressed patients, outcome in the condition of pill
placebo plus clinical management was comparable with outcomes in the
active treatment conditions, suggesting that for such patients “minimal sup-
portive therapy in the hands of an experienced therapist might be sufficient
to bring about a significant reduction of depressive symptomatology” within
a brief, 3- to 4-month treatment (Elkin, 1994, p. 125). The reader is encour-
aged to review Elkin’s (1994) summary of findings on the TDCRP’s other
key and highly practice-relevant questions, including examination of theo-
retically expected specific effects on areas targeted by each of the two spe-
cific forms of psychotherapy and how the treatments compared in rapidity of
improvement.
Promoting Research on Mechanisms of Change
For several years while at NIMH, Elkin headed the Treatment Devel-
opment and Process Research section of the Psychosocial Treatments Research
Branch. She first began to master process research concepts and methods dur-
ing her dissertation study and early work with Carl Rogers and others. Elkin’s
foundation in therapy process research no doubt highlighted, for her, the
TDCRP’s potential value beyond its implications for assessing the efficacy of
psychotherapies. She knew that it also could serve the field as a psychother-
apy process-outcome study, enabling many key theoretical and practice-
relevant mechanisms of action questions to be investigated. Elkin worked
to ensure that the TDCRP’s potential in this regard was realized.
The TDCRP study design, methods, and other planning allowed for
both the collection and archiving of data needed to conduct process-outcome
analyses. For example, standardized instruments as well as measures developed
specifically for the TDCRP were included to examine questions relating to
(a) the effects of patient and therapist characteristics, (b) the therapeutic
relationship, and (c) differential effects of different therapies. Data from such
IRENE ELKIN 83
instruments have been used by a number of researchers as well as by Elkin to
address a variety of questions. For example, based on data from the Attitudes
and Expectations form developed in the TDCRP, Elkin and others found
that congruence between a patient’s assigned treatment and his or her pre-
treatment predilections (patient–treatment fit) predicts early engagement
in therapy (Elkin et al., 1999). Also, in one illustrative TDCRP process-
outcome study, Krupnick et al. (1996) examined the relationship between
the therapeutic alliance and overall treatment outcomes in both the psychother-
apy and pharmacotherapy treatment conditions. The results were a valuable
addition to existing findings that the strength of the patient–therapist alliance
relates to therapy outcomes across treatments.
Generativity
Elkin’s foresight about the TDCRP’s potential to enable both the exam-
ination and heuristic exploration of fundamental mechanisms (process and
process-outcome) questions is among her most generative accomplishments.
Realization of this foresight required her perseverant effort to ensure that
TDCRP data were archived and thereby made widely available to the field.
Elkin oversaw the transfer of the main data to a TDCRP Public Access Data
Tape that many non-TDCRP investigators have used. She also arranged, in
collaboration with two of the TDCRP research sites and Paul Crits-Christoph
at the University of Pennsylvania (UP), to have TDCRP assessment and
treatment session audio- and videotapes archived for use by investigators at
UP. The archives generated influential therapy process and other research
(e.g., Tang & DeRubeis, 1999).
Also, as previously noted, Elkin worked to support and advance psy-
chotherapy research for many years and in a variety of ways via resources
available at NIMH. Her “Fantasied Dialogue” chapter (Waskow, 1975) is an
early illustration of her mentoring via consultation to the field. Prominent
and diverse contemporary investigators who have made major, practice-
relevant contributions, such as Marsha Linehan and Leslie Greenberg, credit
Elkin for nurturing them toward successful therapy research careers. While at
NIMH, Elkin also helped guide the field by taking an active role in the annual
conference of the Society for Psychotherapy Research (SPR). Aside from her
own numerous panels and presentations, her informal, encouraging consul-
tations to researchers remain among her trademarks at SPR conferences. In
her last year at NIMH, Elkin and Ken Howard organized one of the first pre-
SPR institutes on statistical methods useful for psychotherapy research. Elkin
further served the field as an early president of SPR, 1978–1979. Most recently,
Elkin’s mentoring activities as a professor in the School of Social Service
Administration at the University of Chicago helped to expand the role of
84 MORAS AND SHEA

research in clinical social work training—a full circle follow-up to her early
decision to choose psychology over social work because of psychology’s
greater emphasis on research.
We have the good fortune to be able to testify from personal experience
to Irene Elkin’s talent as a mentor. One of us (Shea) began her career work-
ing with Irene as associate coordinator of the TDCRP, a position that had a
tremendous impact on her subsequent career. Those years spent with Irene as
mentor were filled with many wonderful experiences, personally and profes-
sionally. Many qualities made Irene a special mentor. Clearly, her intelligence
and competence stand out. She has a tremendous ability to think through
(and to help others think through) research issues. She was our gold standard.
Another quality of hers is generosity in giving her time. You could walk into
Irene’s office with a question and she would let you sit down and discuss it,
as often as not generating a long and stimulating discussion of all kinds of
research issues and questions. (She and Shea once got so absorbed in such a
discussion that they actually boarded the wrong plane while traveling back
from an SPR meeting.) This giving of time is so rare these days that we have
come to appreciate it even more as the years go on. It is from such informal
discussions that we learned how to think about research.
CONCLUSION
Irene Elkin’s contributions to date have had transformative impacts on

the field of psychotherapy research and also on psychotherapy’s viability as a
socially sanctioned mental health treatment. In the 1960s, early in Elkin’s
career, psychotherapy research was handicapped by many methodological
and conceptual weaknesses (Kiesler, 1966). The TDCRP, to which Elkin
devoted enormous and persistent effort during the mid-phase of her career,
constituted a major antidote to the weaknesses. The TDCRP and subsequent,
similar collaborative, multisite, clinical trial types of studies in which the
effects of medication and psychological treatments could be compared (e.g.,
Barlow et al., 2000) helped answer arguments that were made well into the
1990s that psychotherapeutic treatments, particularly compared with med-
ications, had not been adequately tested and thus could not be assumed to be
efficacious. In addition to the TDCRP’s many influences on therapy research
standards and methods described in this chapter, its successful completion
also demonstrated that psychotherapeutic treatments could be tested on the
same playing field used to test medications.
Aspiring psychotherapy researchers can well serve themselves and
the field by studying closely Elkin’s legacy thus far in (a) papers on basic
methodological/conceptual issues (e.g., Elkin, 1994, 1999); (b) reports of
IRENE ELKIN 85
study findings, because they provide models of clear and precise inductive and
deductive scientific logic, as well as superb methodological and statistical
sophistication (e.g., Elkin et al., 1989; Elkin et al., 2006); (c) rejoinders to
challenges of TDCRP findings because the responses illustrate the strength
of broad and deep scientific expertise, immutable scientific integrity, and the
ability to maintain focus on the key scientific issues at hand (Elkin et al.,
1990, 1996; Elkin, Falconnier & Martinovich, 2007).
We end on a personal note. In addition to her remarkable professional
contributions, Irene has always remained a warm and engaging friend. She is
honest and true and loyal. Her great sense of fun and energy for life can be
heard in her laugh, which is one way to find Irene in a very crowded room.
We are honored and proud to have been among her mentees.
REFERENCES
Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-
behavioral therapy, imipramine, or their combination for panic disorder: A ran-
domized controlled trial. JAMA, 283, 2529–2536. doi:10.1001/jama.283.19.2529
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depres-
sion. New York, NY: Guilford Press.
Elkin, I. (1994). The NIMH Treatment of Depression Collaborative Research Pro-
gram: Where we began and where we are. In A. E. Bergin & S. L. Garfield (Eds.),
Handbook of psychotherapy and behavior change (4th ed., pp. 114–139). New York,
NY: Wiley.
Elkin, I. (1999). A major dilemma in psychotherapy outcome research: Disentan-
gling therapists from therapies. Clinical Psychology: Science and Practice, 6,
10–32. doi:10.1093/clipsy/6.1.10
Elkin, I., Falconnier, L., & Martinovich, Z. (2007). Misrepresentations in Wampold
and Bolt’s critique of Elkin, Falconnier, Martinovich, and Mahoney’s study of
therapist effects. Psychotherapy Research, 17, 253–256.
Elkin, I., Falconnier, L., Martinovich, Z., & Mahoney, C. (2006). Therapist effects
in the NIMH Treatment of Depression Collaborative Research Program. Psycho-
therapy Research, 16, 144–160. doi:10.1080/10503300500268540
Elkin, I., Gibbons, R. D., Shea, M. T., & Shaw, B. F. (1996). Science is not a trial (but
it sometimes can be a tribulation). Journal of Consulting and Clinical Psychology,
64, 92–103. doi:10.1037/0022-006X.64.1.92
Elkin, I., Gibbons, R. D., Shea, M. T., Sotsky, S. M., Watkins, J. T., Pilkonis, P. A.,
. . . Hedeker, D. (1995). Initial severity and differential treatment outcome
in the NIMH Treatment of Depression Collaborative Research Program.
Journal of Consulting and Clinical Psychology, 63, 841–847. doi:10.1037/0022-
006X.63.5.841
86 MORAS AND SHEA

Elkin, I., Pilkonis, P. A., Docherty, J. P., & Sotsky, S. M. (1988a). Conceptual and
methodological issues in comparative studies of psychotherapy and pharmaco-
therapy, I: Active ingredients and mechanisms of change. American Journal of
Psychiatry, 145, 909–917.
Elkin, I., Pilkonis, P. A., Docherty, J. P., & Sotsky, S. M. (1988b). Conceptual and
methodological issues in comparative studies of psychotherapy and pharmaco-
therapy, II: Nature and timing of treatment effects. American Journal of Psychiatry,
145, 1070–1076.
Elkin, I., Shea, M. T., Collins, J. F., Klett, C. J., Imber, S. D., Sotsky, S. M., . . .
Parloff, M. B. (1990). NIMH Collaborative Research on Treatment of Depres-
sion [Letter to the editor]. Archives of General Psychiatry, 47, 684–685.
Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F.,
. . . . Parloff, M. B. (1989). National Institute of Mental Health Treatment of
Depression Collaborative Research Program: General effectiveness of treat-
ments. Archives of General Psychiatry, 46, 971–982.
Elkin, I., Yamaguchi, J. L., Arnkoff, D. B., Glass, C. R., Sotsky, S. M., & Krupnick,
J. L. (1999). “Patient-treatment fit” and early engagement in therapy. Psycho-
therapy Research, 9, 437–451. doi:10.1093/ptr/9.4.437
Hill, C. E., O’Grady, K. E., & Elkin, I. (1992). Applying the Collaborative Study
Psychotherapy Rating Scale to rate therapist adherence in Cognitive-Behavior
Therapy, Interpersonal Therapy, and Clinical Management. Journal of Consult-
Hollon, S. D., Waskow, I. E., Evans, M., & Lowry, H. A. (1984, May). System for
rating therapies for depression. Paper presented at the annual meeting of the
American Psychiatric Association, Los Angeles, CA.
Kiesler, D. J. (1966). Some myths of psychotherapy research and the search for a
paradigm. Psychological Bulletin, 65, 110–136. doi:10.1037/h0022911
Klerman, G. L., Weissman, J. M., Rounsaville, B. J., & Chevron, E. S. (1984). Inter-
personal psychotherapy of depression. New York, NY: Basic Books, Inc.
Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J. T.,
. . . Pilkonis, P. A. (1996). The role of the therapeutic alliance in psychotherapy
and pharmacotherapy outcome: Findings in the NIMH Treatment of Depres-
sion Collaborative Research Program. Journal of Consulting and Clinical Psychol-
ogy, 64, 532–539. doi:10.1037/0022-006X.64.3.532
Parloff, M. B., & Elkin, I. (1992). Historical developments in research centers: The
NIMH Treatment of Depression Collaborative Research Program. In D. K.
Freedheim (Ed.), History of psychotherapy: A century of change (pp. 442–449).
Shaw, B. F., Elkin, I., Yamaguchi, J., Olmstead, M., Vallis, T. M., Dobson, D. S.,
. . . Imber, S. D. (1999). Therapist competence ratings in relation to clinical
outcome in cognitive therapy of depression. Journal of Consulting and Clinical
Psychology, 67, 837–846. doi:10.1037/0022-006X.67.6.837
IRENE ELKIN 87
Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive-
behavioral therapy for depression. Journal of Consulting and Clinical Psychology,
67, 894–904. doi:10.1037/0022-006X.67.6.894
Waskow, I. E. (1975). Fantasied dialogue with a researcher. In I. E. Waskow & M. B.
Parloff (Eds.), Psychotherapy change measures: Report of the Clinical Research
Branch Outcome Measures Project (pp. 273–327). Washington, DC: U.S. Gov-
ernment Printing Office.
Waskow, I. E., & Parloff, M. B. (Eds.). (1975). Psychotherapy change measures: Report
of the Clinical Research Branch Outcome Measures Project. Washington, DC: U.S.
Government Printing Office.
88 MORAS AND SHEA

8
KENNETH I. HOWARD: THE BEST
FRIEND THAT PSYCHOTHERAPY
RESEARCH EVER HAD
DAVID E. ORLINSKY, MERTON S. KRAUSE, FREDRICK L. NEWMAN,
ROBERT J. LUEGER, AND WOLFGANG LUTZ
Kenneth Irwin Howard was born in 1932 and died in 2000. He was a
professor of psychology at Northwestern University in Evanston, Illinois,
for 32 years, and before that was deputy director of research and chief of
the program in measurement and evaluation at the Illinois Department of
Mental Health’s Institute for Juvenile Research. In these positions, he
made major contributions to the field of psychotherapy research and also
to research on adolescence and delinquency, psychometrics, and clinical
research methodology. Howard coauthored six books and more than 175 book
chapters, articles, and research instruments. He served as coeditor of
the Journal of Clinical Psychology (1996–2000) and as consulting or associ-
ate editor for six other journals. He held a National Institute of Mental
Health (NIMH) Senior Research Scientist Award and was a fellow of the
American Psychological Association’s (APA’s) Divisions 5 (Evaluation,
Measurement, and Statistics), 12 (Society of Clinical Psychology), and
29 (Psychotherapy), the American Psychological Society, the Association
The first four sections were prepared by David E. Orlinsky; the fifth section was prepared by Frederick L.
Newman, Robert J. Lueger, and David E. Orlinsky; the sixth section was prepared by Robert J. Lueger;
the seventh section was prepared by Wofgang Lutz; and the eighth and ninth sections were prepared by
Fredrick L. Newman. All coathors shared in the final version.
89
for Clinical Psychosocial Research, and the American Association for the
Advancement of Science. He cofounded and led the Society for Psy-
chotherapy Research. His scientific and professional work has been recog-
nized by many major groups, including APA.
EARLY INFLUENCES
Ken Howard began his graduate training in psychology at the Univer-

sity of Chicago in autumn of 1956, having been attracted both to the field of
psychology and to the University of Chicago by a course he took as an under-
graduate at the University of California–Berkeley from a visiting Chicago
professor named Carl Rogers. The psychology department at Chicago in the
1950s presented a broad variety of intellectual influences with no one clearly
dominant, which allowed students great leeway in choosing those that were
most congenial to their talents. In this rich environment, Howard was not
initially drawn to the study of psychotherapy—despite the presence of
Rogers at the University of Chicago Counseling Center; instead he became
intrigued with quantitative methods and discovered a special talent for
research design, measurement, psychometrics, and statistics. Most influen-
tial for his development were methodologists like Campbell and Fiske, psycho-
metricians like L. L. Thurstone, and factor analysts like Thurstone and
Raymond Cattell (University of Illinois). Howard’s early research focused on
issues related to psychological assessment and included participation in a large-
scale study of delinquency, street-corner youth, and, later on, adolescent
development (with Daniel Offer). He also completed a clinical internship
and worked at the clinic, where he began his research on psychotherapy.
PATIENTS’ AND THERAPISTS’ EXPERIENCES IN THERAPY
With a friend and fellow graduate student (D. Orlinsky) Howard in

1964 undertook a collaborative study of patients’ and therapists’ experiences
during therapy sessions. Their Psychotherapy Session Project aimed to answer
questions arising from their shared experiences as part-time staff therapists at
a clinic. The instruments they developed to reflect and illuminate the “psy-
chological interior of psychotherapy” were parallel patient and therapist ver-
sions of the Therapy Session Report (Orlinsky & Howard, 1975), one of the
first in a long line of postsession questionnaires that researchers have used to
explore and evaluate therapy process.
A stream of journal articles based on patients’ and therapists’ experiences
appeared from the late 1960s (e.g., Howard, Krause, & Orlinsky, 1969) to the
90 ORLINSKY ET AL.
late 1970s (e.g., Howard, Orlinsky, & Perilstein, 1976), culminating in a book
on the Varieties of Psychotherapeutic Experience (Orlinsky & Howard, 1975).
These studies demonstrated the feasibility and the importance of methodolog-
ically objective research on subjective experience for understanding the process
of therapy, going well beyond the clinical case history in rigor yet also correct-
ing the overreliance of process researchers on audio recordings.
Ken Howard’s most distinctive contribution to this project was his talent
for psychological measurement and quantitative analysis and his singular per-
spective on clinical work. Through a deft strategy of multilevel factor and clus-
ter analyses, Howard empirically defined the dimensions and types of patients’
in-session experience, therapists’ in-session experience, and their often oblique
but clinically significant interdependence. The latter include several patterns
of conjoint experience, such as therapeutic alliance vs. defensive impasse,
healing magic vs. uncomfortable involvement, and sympathetic warmth
vs. conflictual erotization, where the experiences of patient and therapist were
statistically linked despite apparent differences in their manifest content
(Orlinsky & Howard, 1975). These patterns provide clues for therapists about
the nature of a patient’s experience, not through observing the patient directly
but rather by focusing on their own experiences during sessions.
PROCESS–OUTCOME RESEARCH REVIEWS

AND THE GENERIC MODEL OF THERAPY
Because of his rising prominence, Howard was invited to write a review

of psychotherapy process research for the 1972 issue of the Annual Review of
Psychology. This was well received and brought an invitation from Bergin and
Garfield to review research linking therapeutic processes to outcomes for the
second edition of their esteemed Handbook of Psychotherapy and Behavior
Change and, 8 years later, to the third edition as well. Work on the latter led
to the formulation of a systematic, research-based model—the Generic Model
of Psychotherapy—that integrated the cumulative findings of research in the
field in a coherent conceptual framework and offered a way to integrate rival
clinical theories as well (Orlinsky & Howard, 1986).
The Generic Model organized the variables that researchers have studied
into three broad categories: input, process, and output. Input variables include
conditions that are temporally prior and (potentially) causally related to the
events of therapy: patients’ and therapists’ personal and professional charac-
teristics and the institutional and cultural environments in which therapy
takes place. Output variables include conditions that are temporal and (poten-
tially) causal sequelae of the events of therapy, especially their consequences
for the patient (clinical outcome) but also for the therapist (e.g., professional
KENNETH I. HOWARD 91
growth, burnout), for other persons in patients’ and therapists’ lives, and for the
social and cultural environments in which therapy takes place. Research on
both input and output variables were examined in relation to the varied facets
of therapeutic process that researchers had studied. The latter included the ther-
apeutic contract (e.g., goals, methods, schedule, fees), therapeutic operations
(intervention procedures or techniques), the therapeutic bond (interpersonal
rapport and compatibility), patient’s and therapist’s internal self-relatedness
(openness, defensiveness), and therapeutic realizations (in-session impacts).
The predictive value of the Generic Model was subsequently tested in several
studies (e.g., Kolden & Howard, 1992; Saunders, Howard & Orlinsky, 1989).
NORTHWESTERN–CHICAGO STUDY
Inspired in part by their reviews of research on the relation of therapeutic

process to outcome (as depicted in the Generic Model), Howard and Orlinsky
and their collaborators in the mid-1980s established the Northwestern–
Chicago Psychotherapy Research Program. This included in its aims “predict-
ing treatment duration (service utilization) and treatment effectiveness by
means of early therapy indicators, such as the quality of the early therapeutic
bond or the initial level of symptomatic distress,” and “interest in the rela-
tionships among length of treatment, phases of therapy, and treatment effec-
tiveness” (Howard et al., 1991, pp. 65–66). Supported by NIMH grants, the
project continued for nearly 8 years and produced many studies having meas-
urement, process–outcome, and policy implications.
Most significant for the further development of Howard’s work was his
use of measures developed in the Northwestern–Chicago project to devise an
outcome assessment battery for use by a managed care service delivery net-
work (Howard, Lueger, & Kolden, 1997). This included a patient self-report
inventory, therapist rating scales, a patient-rated measure of therapeutic
alliance, and a survey of presenting problems. Data from over 16,000 patients
established broad-based norms and made possible studies of patient change
over time that led to the dose–effect model, the outcome phase model, and
patient-focused research.
THE PROCESS OF OUTCOME: DOSE–EFFECT

AND OUTCOME PHASE MODELS
To understand the relationship between the amount of psychotherapy

and the benefit or outcome of that psychotherapy, Howard and colleagues had
to address two problems. The first problem was how to measure a unit of treat-
92 ORLINSKY ET AL.
ment despite the diverse theories and processes of treatment. The solution to
this problem was essential to solving the second problem—identifying a
mathematical model that would describe the relationship between amount of
treatment and amount of effect. The potential value of a mathematical model
lay in its ability to predict the amount of benefit for selected durations of treat-
ment and thus to identify those applicants for psychotherapy who are in need
of treatment and to set rational limits on the duration of therapy.
Analyzing data on 2,431 patients from 15 studies conducted by them-
selves or others over a period of 30 years, Howard and his colleagues identi-
fied a log-linear relationship between the amount of therapy (dose) and the
amount of improvement (effect) in which the outcome of interest was the
proportion of patients achieving a dichotomously expressed result (improved
or not improved). This has become known as the dose–effect model (Howard,
Kopta, Krause, & Orlinsky, 1986). Improvement could be mathematically
modeled by a negatively accelerating curve with a higher frequency of improve-
ment earlier compared with later in treatment. The extrapolated curve did not
reach zero at its origin but suggested that 10% to 18% (expressed in confidence
intervals) of patients showed some improvement even before the first session
of psychotherapy, possibly as a result on the patient’s sense of efficacy in hav-
ing made the appointment. With eight sessions of psychotherapy, 48% to
58% of the patients showed a measurable degree of improvement, and after a
year of treatment, the improvement curve approached asymptote, with about
85% of patients having shown some improvement. By the common criterion
of effective exposure used in pharmacological dosage studies, the amount of
psychotherapy at which 50% of patients respond to treatment is about six to
eight sessions. Analyses taking account of diagnosis at intake revealed that
dosage estimates vary in relation to patient characteristics. Finally, the upper
bound of responsiveness to psychotherapy, approximately 85% improvement,
matched the results of earlier large meta-analyses of psychotherapy outcomes.
In the 20 years after its publication, the dose–effect paper was cited
over 350 times in the psychological or medical literature, providing a mea-
sure of its influence on other researchers. The dose–effect relationship iden-
tified by Howard has been replicated by colleagues in his own group using
larger samples and different self-report measures of improvement, and by
other researchers with even larger sample sizes, different self-report measures,
and alternative statistical analyses such as survival analysis.
Introduction of the phase model of outcome extended the dose–effect
model to explore the differential response rates of diverse outcome domains
(Howard, Lueger, Maling, & Martinovich, 1993). The phase model showed
that three problem areas—general demoralization, symptoms, and deficits
in life functioning—tend to change at different rates, and perhaps at differ-
ent times, in the improvement trajectory. These changes define outcome
phases defined as remoralization, remediation of symptoms, and rehabilita-
tion of deficits.
The phase model proposes that these phases occur in a sequence sug-
gesting a probable causal order. In the remoralization phase, clients begin to
recover from feelings of powerlessness and hopelessness. This may start with
the client taking steps to seek help, and it may continue in early sessions of
therapy as symptoms and problems are clarified, some initial success in mas-
tery of problems is realized, and clients gain hope that therapy will help in
addressing their problems. In the remediation phase, therapy mobilizes the
client’s coping skills and continues to develop a sense of mastery or control,
resulting in the reduction of symptomatic distress. In the rehabilitation
phase, clients attempt to modify or control long-standing maladaptive pat-
terns of thought and behavior, to develop more adaptive interpersonal and
self-management skills, and to consolidate their ability to achieve positive
change in their lives.
The value of the phase model for investigators is indicated by the
many times it has been cited in the research literature. The basic precepts
of the model—domains and probabilistic causal sequence—have been repli-
cated in a large sample of patients using somewhat different measures of the
same constructs. The value of the model for those who formulate service
delivery policy is that it informs the stakeholders how much treatment will
likely be required to produce improvement in various outcome domains.
PATIENT-FOCUSED RESEARCH
AND EXPECTED TREATMENT RESPONSE
In 1996, Ken Howard and colleagues introduced the concept of patient-

focused research, which has since become the standard term for a new paradigm
in psychotherapy research (Howard, Moras, Brill, Martinovich, & Lutz, 1996).
Patient-focused research involves the evaluation and outcomes management
of psychological treatments in naturalistic service delivery settings, often while
the therapy is in progress. Howard and colleagues drew a distinction between
two traditions of outcome studies—efficacy research and effectiveness
research—and proposed patient-focused research as an alternative strategy.
Each strategy has strengths and weaknesses.
Efficacy research addresses the question of how well a treatment works
under experimentally controlled conditions (i.e., whether the intervention
produces better outcomes than a commonly used treatment or than a puta-
tively inert placebo condition). However, it compares the average response
of patients in different groups and says nothing about individual patients.
Moreover, the effort to maintain experimental controls raises questions about
94 ORLINSKY ET AL.
the generalizability of results to uncontrolled real-world settings where inter-
nal validity often is compromised by treatment delivery conditions (Howard,
Krause, & Orlinsky, 1986; Howard, Orlinsky, & Lueger, 1995).
Effectiveness research addresses the question of how well a treatment works
as it is administered in actual clinical settings. These studies emphasize the gener-
alizability of findings (external validity) and deal with the application of validated
treatments to the circumstances of clinical practice. However, the quasi-exper-
imental and systematic naturalistic designs of effectiveness research tend to
sacrifice certainty of internal validity. Moreover, like efficacy research, effec-
tiveness research says nothing about the progress of an individual patient.
Patient-focused research, by contrast, asks how well a particular treatment
works for individual patients (i.e., whether the patient’s condition is respond-
ing to the treatment). This model recognizes that patients differ in their
expected outcomes or expected courses of treatment. To understand and eval-
uate the observed course of an individual’s response to therapy, one needs to
know the reasonable expected course of treatment for that patient, and a
method for calculating an expected treatment response was developed using
hierarchical linear modeling. This approach provides an individualized pro-
file of each patient’s progress in relation to the expected course of treatment
response for that patient by modeling a patient’s change over treatment as
a log-linear function of session number and pretreatment clinical charac-
teristics (Lutz, Martinovich, & Howard, 1999). The prediction weights of
a patient’s initial clinical status and the individual differences in growth
curve characteristics allow the prediction of the course of treatment for
individual patients once their intake information is available. Ongoing
therapeutic effectiveness can be assessed for a single patient by tracking the
patient’s actual progress in comparison with expected progress based on pre-
treatment clinical characteristics.
In addition to many different research and outcomes management
applications, the value of the model for clinical practice has been illus-
trated with many examples of successful and unsuccessful treatment cases.
Further studies using this model have found (a) that predictions for change
in later sessions are enhanced by incorporating information about the
change that patients experienced during early sessions, (b) that initial pre-
dictions based on patient characteristics are reliable, (c) that predictions
are useful for clinical case management, (d) that the model can be applied
to different diagnostic groups and various symptom patterns, and (e) that
a three-level hierarchical linear model can identify differential therapist
influence on patient change.
Ken Howard recognized that the validity of growth curve prediction
weights for any particular patient depends on the extent to which the study
sample (reference group) is representative of the population of which that
patient was a member and that most predictors work only for specific sub-
sets of patients (Krause, Howard, & Lutz, 1998). To address this problem,
an extended expected response model using nearest neighbor techniques
was introduced. The nearest neighbor approach identifies those previously
treated patients in the reference group who most closely match the target
patient (hence “nearest neighbors”) on intake variables. It then uses this
homogeneous subgroup to generate predictions of treatment progress for the
target patient.
The patient-focused model has been applied to large databases in the
United Kingdom and the United States, and it has been used for continuous
patient feedback into clinical practice to identify potential treatment failures
early in the course of therapy. In this respect, patient-focused research has the
potential to inform the clinical decisions of therapists in the course of treat-
ment and thus to reduce the scientist–practitioner gap (Howard et al., 1996).
DEVELOPING AN EMPIRICAL BASIS FOR

MENTAL HEALTH SERVICE POLICY
For many years Howard and his colleagues argued that the random-
ized clinical trial had only limited use in setting the standards and policies
for what is now called evidence-based practice (Howard, Krause, & Lyons,
1993; Krause & Howard, 2003). They clarified issues, such as attrition and
selection bias, that severely limited the inferences that can be drawn from
randomized clinical trials, and they stressed the inadequacy of relying only
on mean group differences and effect sizes to assess the value of treatments
(Howard, Krause, & Vessey, 1994). They promoted the use of “systematic
naturalistic” designs in studies, following a research protocol implemented
in actual treatment settings with a minimum of intrusion on the clinical
practice (Howard et al., 1996). In place of no-treatment and/or alternative-
treatment control conditions, Howard argued for comparison of clinical
samples with representative samples of “normal” persons in order to assess
whether, and to what extent, patients progressed in a clinically significant
direction, that is, toward behaviors statistically indistinguishable from
those in a nonclinical population similar to those who entered treatment.
Over a series of studies, they argued that one could provide an empirical
basis for assessing the clinical significance of specific interventions as a
function of a variety of moderator variables and thereby estimate what
works best for whom (Howard, Krause, Caburnay, Noel, & Saunders, 2001;
Howard, Krause, & Lyons, 1993; Lutz, Martinovich, & Howard, 1999;
Lyons & Howard, 1991; Saunders, Howard, & Newman, 1988). Howard
and his colleagues must be recognized as pioneers in the use of what is now
96 ORLINSKY ET AL.
called practice-based evidence, which became possible in large part through
his example in the application of sound statistical methods and his leader-
ship in encouraging others to depart from exclusive reliance on data from
randomized clinical trials.
ADVANCES IN THE APPROPRIATE ANALYSES

OF PSYCHOTHERAPY RESEARCH DATA
Howard’s emphasis on the logical application of statistical methods and

use of appropriate research designs should have a significant impact on
mental health service practice and policy. At the level of statistical analy-
sis, he advocated the collection of systematic quantitative data in natura-
listic settings in order to focus on estimating “what works for whom.”
Howard’s work in this area indicated that there are three questions that
need to be answered by researchers to test for statistical equivalence or dif-
ference of patients’ test scores from acceptable or “normal” psychological
and social functioning:
1. What are the relevant population characteristics and appropriate
measures of outcome? An explicit statement must be made of
the characteristics of the sample and population and of the
measures to be used in a comparison. Desired behavioral out-
comes must be tailored to the “whom” in the question, “What
works for whom?”
2. How much difference makes a real difference? The upper and lower
limits of equivalence or difference must also be described a pri-
ori and defended on the basis of relevant theory or established
empirical findings. Researchers and policymakers need to define
the range of behaviors that are reliable and valid indicators
of clinically appropriate (“normal”) behaviors as distinct from
those that would be considered “abnormal.”
3. What is an acceptable rate of being wrong (Type I error)? The prob-
ability that the confidence interval falls outside of the bound-
aries of equivalence must be explicitly acknowledged if one is
to follow the current scientific tradition of statistical decision
making. This is essential for evaluating either a single study or
a set of studies in a meta-analysis, as well as defining criteria for
generating supervisory feedback to therapists and setting policy
boundaries for acceptable evidence-based practice.
In addition to his own writing about the potential policy implications of
research, Howard made strong and consistent efforts to support colleagues as
they developed methods capable of providing data from naturalistic settings
that could impact treatment guidelines and standards and influence evidence-
based practice and policy (e.g., in special issues of the Journal of Consulting and
Clinical Psychology that he instigated). The influence of Ken Howard’s later
research may be seen in the adaptation by several research groups of the clin-
ical significance concept and community norms in their use of practice-based
evidence and clinical progress feedback to the therapists as means of improv-
ing service outcomes in the United States, United Kingdom, Switzerland, and
Germany; the development of new instrumentation for assessing outcomes
of mental health services; and the development of practice-based research
networks.
It is probably no accident that the research groups that have done most to
develop and apply these concepts, methods, and statistical procedures had their
intellectual home in the Society for Psychotherapy Research—a society that
Howard cofounded and served as its first president and later as its first executive
officer. In all his work, Ken Howard was known as a man of remarkable intelli-
gence, unusual wit, and great personal charm. He is remembered by us and many
others as a devoted friend and generous mentor.
REFERENCES
Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose-effect
relationship in psychotherapy. American Psychologist, 41, 159–164.doi:10.1037/
0003-066X.41.2.159
Howard, K. I., Krause, M. S., Caburnay, C. A., Noel, S. B., & Saunders, S. M. (2001).
Syzygy, science, and psychotherapy: The Consumer Reports study. Journal of Clin-
ical Psychology, 57, 865–874. doi:10.1002/jclp.1055
Howard, K. I., Krause, M. S., & Lyons, J. S. (1993). When clinical trials fail: A guide
to disaggregation. In L. S. Onken, J. D. Blaine, & J. J. Boren (Eds.), Behavioral
treatments for drug abuse and dependence (NIDA Research Monograph No. 137,
pp. 291–302). Washington, DC: National Institute for Drug Abuse.
Howard, K. I., Krause, M. S., & Orlinsky, D. E. (1969). Direction of affective influence
in psychotherapy. Journal of Consulting and Clinical Psychology, 33,614–620.
doi:10.1037/h0028299
Howard, K. I., Krause, M. S., & Orlinsky, D. E. (1986). The attrition dilemma:
Toward a new strategy for psychotherapy research. Journal of Consulting and Clin-
ical Psychology, 54, 106–110. doi:10.1037/0022-006X.54.1.106
Howard, K. I., Krause, M. S., & Vessey, J. (1994). Analyzing clinical trial data: The
problem of outcome overlap. Psychotherapy, 31, 302–307. doi:10.1037/h0090213
Howard, K. I., Lueger, R. J., & Kolden, G. G. (1997). Measuring progress and out-
come in the treatment of affective disorders. In L. M. Horowitz, M. J. Lambert,
98 ORLINSKY ET AL.
& H. H. Strupp (Eds.), Measuring patient change after treatment for mood, anxiety,
and personality disorders: Toward a core battery (pp. 263–281). Washington, DC:
Howard, K. I., Lueger, R. J., Maling, M. S., & Martinovich, Z. (1993). A Phase Model
of psychotherapy: Causal mediation of change. Journal of Consulting and Clinical
Psychology, 61, 678–685. doi:10.1037/0022-006X.61.4.678
Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation
of psychotherapy: Efficacy, effectiveness, and patient progress. American Psychol-
ogist, 51, 1059–1064. doi:10.1037/0003-066X.51.10.1059
Howard, K. I., & Orlinsky, D. E. (1972). Psychotherapeutic processes. In P. H. Mussen
& M. R. Rosenzweig (Eds.), Annual review of psychology (Vol. 23, pp. 615–668).
Palo Alto, CA: Annual Reviews.
Howard, K. I., Orlinsky, D. E., & Lueger, R. J. (1995). The design of clinically rele-
vant outcome research: Some considerations and an example. In M. Aveline &
D. A. Shapiro (Eds.), Research foundations for psychotherapy practice (pp. 3–47).
Chichester, England: Wiley.
Howard, K. I., Orlinsky, D. E., & Perilstein, J. (1976). Contributions of therapists
to patients’ experiences in psychotherapy: A components of variance model
for analyzing process data. Journal of Consulting and Clinical Psychology, 44,
520–526. doi:10.1037/0022-006X.44.4.520
Howard, K. I., Orlinsky, D. E., Saunders, S. M., Bankoff, E., Davidson, C., &
O’Mahoney, M. (1991). Northwestern University–University of Chicago psy-
chotherapy research program. In L. E. Beutler & M. Crago (Eds.), Psychotherapy
research: An international review of programmatic studies (pp. 65–74). Washing-
ton, DC: American Psychological Association.
Kolden, G. G., & Howard, K. I. (1992). An empirical test of the Generic Model of
Psychotherapy. Journal of Psychotherapy Practice and Research, 1, 225–236.
Krause, M. S., & Howard, K. I. (2003). What random assignment does and does not
do. Journal of Clinical Psychology, 59, 751–766. doi:10.1002/jclp.10170
Krause, M. S., Howard, K. I., & Lutz, W. (1998). Exploring individual change.
006X.66.5.838
Lutz, W., Martinovich, Z., & Howard, K. I. (1999). Patient profiling: An application
of random coefficient regression models to depicting the response of a patient to
outpatient psychotherapy. Journal of Consulting and Clinical Psychology, 67,
571–577. doi:10.1037/0022-006X.67.4.571
Lyons, J. S., & Howard, K. I. (1991). Main effects analysis in clinical research: Sta-
tistical guidelines for disaggregating treatment groups. Journal of Consulting and
Clinical Psychology, 59, 745–748. doi:10.1037/0022-006X.59.5.745
Orlinsky, D. E., & Howard, K. I. (1975). Varieties of psychotherapeutic experience:
Multivariate analyses of patients’ and therapists’ reports. New York, NY: Teachers
College Press.
Orlinsky, D. E., & Howard, K. I. (1978). The relation of process to outcome in psycho-
therapy. In S. Garfield & A. Bergin (Eds.), Handbook of psychotherapy and behav-
ior change (2nd ed., pp. 283–329). New York, NY: Wiley.
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In
S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior
change (3rd ed., 311–384). New York, NY: Wiley.
Saunders, S. M., Howard, K. I., & Newman, F. L. (1988). Evaluating the clinical
significance of treatment effects: Norms and normality. Behavioral Assessment,
10, 207–218.
Saunders, S. M., Howard, K. I., & Orlinsky, D. E. (1989). The Therapeutic Bond
Scale: Psychometric characteristics and relationship to treatment effectiveness.
Psychological Assessment, 1, 323–330. doi:10.1037/1040-3590.1.4.323
100 ORLINSKY ET AL.

9
ALLEN E. BERGIN: CONSUMMATE
SCHOLAR AND CHARTER
MEMBER OF THE SOCIETY FOR
PSYCHOTHERAPY RESEARCH
MICHAEL J. LAMBERT, ALAN S. GURMAN, AND P. SCOTT RICHARDS
Allen E. Bergin has been a guiding light for the development and
growth of psychotherapy by demonstrating that psychotherapy works for the
majority of clients, pointing out the harm that psychotherapy can do, encour-
aging the use of a broad range of research methods that inform clinical practice,
and integrating new dimensions of human functioning in our understand-
ing and facilitation of change. These impressive contributions are noteworthy
in scientific, clinical, and practice communities over a span of 40 years. At the
center of Bergin’s influence on the field is the publication of the seminal Hand-
book of Psychotherapy and Behavior Change, his outstanding scholarship on the
general effects of psychotherapy, his inspirational effort to stimulate collabo-
ration in psychotherapy research, his timely analysis of deterioration effects,
his examination of the therapeutic effectiveness of paraprofessionals, and his
opening up new horizons of scholarship and research on religious values and
spirituality.
101
EARLY BEGINNINGS
Of special import with regard to Bergin’s contributions to psychotherapy

is the fact that he was trained first as a behavior therapist under the tutelage
of Albert Bandura at Stanford University and, after receiving his PhD, did a
postdoctoral fellowship focused on client-centered psychotherapy under
Carl Rogers at the University of Wisconsin. Perhaps not at all ironically,
after that postdoctoral year, Bergin joined the clinical psychology faculty
at Columbia University (Teachers College [TC]), the program from which
Rogers had received his PhD in 1931. The professional and intellectual
atmosphere at the TC clinical psychology program could not have been bet-
ter suited to Bergin’s scholarly openness and natural inclination toward
academic inclusiveness. Despite its location in the geographic center of
psychoanalytic and psychodynamic ferment that was New York City, the TC
program’s faculty was diverse long before diversity became a household word.
In the last few years of Bergin’s tenure at TC (which he left in 1972 to move to
Brigham Young University in Provo, Utah), the program’s faculty included a
Sullivanian psychoanalyst, a community psychologist, a “Tavistock”-style group
therapist, a developmental psychopathologist, and a Rorschach researcher, in
addition to Bergin’s very empirically iconoclastic colleague and Handbook
coeditor, Sol Garfield. Bergin highly valued a community of nonredundant
ideas in his professional environment.
The same intellectual openness and searching that characterized Bergin’s
profoundly important writings also permeated his teaching at TC. For exam-
ple, while demonstrating to his graduate student seminar on behavior therapy
the actual conduct of systematic desensitization (very popular in 1968!), his
authority-phobic client spontaneously reported a recent dream. The dream
seemed to be speaking to the unconscious ways in which his experiencing
therapeutic change regarding authority figures was evolving during his work
with Bergin. Behavior therapist though he may have been, Bergin was clearly
fascinated to hear the young man’s account of his unconscious responding to
such a direct behavioral intervention. He urged his students to appreciate the
complexity and multidimensionality of human behavior and, thus, of the
process of therapeutic change at a time when acrimonious debates between
theoretical schools were more abundant than efforts toward integration and
rapprochement.
It is not entirely clear if Bergin was able to provide such objective and
balanced reviews of psychotherapy research because of his clinical training
in learning theory and his early exposure to client-centered psychotherapy
research or if he sought out this kind of diverse training because of his intel-
lectual curiosity and openness. In any event, he was able to document what
no one before him had been able to, that is, the existence of overwhelming
102 LAMBERT, GURMAN, AND RICHARDS

evidence that people who are suffering with personal problems are better off
seeing psychotherapists than going it on their own and hoping for their prob-
lems to abate.
The Handbook
For most of its early history (extending into the 1930s) psychotherapy
relied almost exclusively on clinical reports, case studies, and theoretical
accounts of the effects of psychotherapy. Practice was based on theoretical alle-
giance with reference to authority figures or recourse to personal clinical expe-
rience. By 1970, a sufficient body of psychotherapy research existed to enable
Allen Bergin and Columbia University (TC) colleague Sol Garfield to edit
the first edition of the Handbook of Psychotherapy and Behavior Change (Bergin
& Garfield, 1971). Their anticipation was that the exponential increase in
empirical research would
guide practice so that harmful and useless methods will be discarded and
the best techniques (whether they be drugs, different methods of psycho-
therapy, or social intervention) will be used in the most efficient manner
to help individuals overcome their problems. (Bergin & Garfield, 1971,
p. xii)
Over its history, the Handbook became the primary reference on the
critical review and integration of empirical investigations of all the major
methods of psychotherapy. It rapidly ascended to the status of required read-
ing for a majority of graduate programs in clinical and counseling psychology,
and thereafter became a Science Citation Classic. It is not difficult to judge
the importance of the first and subsequent editions of the Handbook. Gener-
ations of practitioners have been guided by the carefully integrated evidence
for positive clinical practice and equally as important, it had a significant
influence on the nature and types of questions that were being asked and the
methodologies that guided psychotherapy researchers for decades.
Evaluation of Psychotherapy Outcome
Of considerable significance was Bergin’s chapter in the first edition,

“The Evaluation of Psychotherapy Outcomes,” in which he addressed and
almost put to rest one of the most resistant myths of the 20th century: that
psychotherapy’s impact on patients was no more helpful than the passage of
time. This conclusion, prompted by a review of the existing research literature
ALLEN E. BERGIN 103

by Hans Eysenck (1952), had been hotly debated with strong invective,
claims, and counterclaims over 2 decades. The traditional verbal therapies
were under attack, but the research evidence Eysenck had relied on had been
so ambiguous that it was open to numerous interpretations. Bergin was the first
scholar in the field to approach the debate by carefully reexamining the evi-
dence put forth by Eysenck. He documented numerous problems in the
original studies that made them difficult to combine, and he found computa-
tional errors in both the original studies and in Eysenck’s own calculations
and tabulations of improvement rates based on those original studies, as well
as a consistent tendency on Eysenck’s part to interpret information about the
results of psychodynamic psychotherapy in as negative a light as possible. The
result was that Bergin’s scholarship was so careful and clear that it illuminated
the misinterpretations and cast serious doubt on the validity of Eysenck’s orig-
inal conclusions. As psychotherapy research methodology improved over the
35 years after that seminal analysis, and as quantitative reviewing tech-
niques rose to prominence, Bergin’s conclusions were substantiated, whereas
Eysenck’s have not been supported. We know that at the very least a wide
variety of psychotherapies speed recovery even if their helpfulness does not
ultimately surpass the natural healing effects of the passage of time. Bergin’s
tireless scholarship was without doubt the largest single reason the debate
finally faded away. It is quite unfortunate that many of today’s graduate stu-
dents do not read this fine chapter, because it provides such a high standard
of critical scholarship for anyone seriously interested in integrating research
evidence into the ethical and effective practice of psychotherapy.
Changing the Frontiers of Psychotherapy Research
As compelling as Bergin’s (1971) critiques of Eysenck’s analyses were,

and as defining of the world of psychotherapy research as the Handbook was,
arguably his crowning written achievement in the field, and certainly the most
creative and generative, was the extraordinary project he undertook with Hans
Strupp of Vanderbilt University. Following the American Psychological Asso-
ciation Conference on Research in Psychotherapy in 1966, Bergin and Strupp
undertook the massive joint project of attempting to stimulate collaborative
research among independent psychotherapy investigators. The first product of
this collaboration was “Some Empirical and Conceptual Bases for Coordinated
Research in Psychotherapy,” published as an entire issue of the International
Journal of Psychiatry (Strupp & Bergin, 1969a). This groundbreaking call for
collaborative therapy research was followed by Bergin and Strupp’s joint
preparation of another issue of that journal (Strupp & Bergin, 1969b), which
consisted of commentaries by most of the world’s leading therapy researchers

on the earlier proposal to foster collaborative work on the central challenging
issues and questions of the times (Strupp & Bergin, 1969a).
As innovative as those two publications were in the field, they could
only be exceeded in their mind-expanding potential by the ultimate appear-
ance of Bergin and Strupp’s (1972) Changing Frontiers in the Science of Psycho-
therapy, probably the most visionary single published contribution to the
evolution of psychotherapy research. In their quest to arouse a collaborative
investigative spirit among like-minded clinical scholars, Bergin and Strupp
obtained a federal research grant that allowed them to travel to visit and
interview at length such conceptually diverse luminaries as Thomas Szasz,
Kenneth Colby, Robert Wallerstein, Neal Miller, Peter Lang, and Gerald
Davison. These interviews and Bergin and Strupp’s reflections on these inter-
views constitute a truly unique contribution to the history of psychotherapy
research. As Joseph Matarazzo wrote in his foreword to Changing Frontiers,
Bergin and Strupp’s commentaries and reflections illustrate and embody “the
thoughts, hopes, aspirations, convictions, biases, frustrations, changes of
heart and viewpoint, the excitement and despair experienced by every writer
and scientist as he pursues his work” (p. vi).
Among Bergin’s more important observations was that posttest scores
on assessments of client functioning demonstrated greater variance than had
been present at intake, and greater than in no-treatment controls. Bergin
described this common occurrence as the deterioration effect and became the
central figure in advocating the possibility that therapy was, on occasion,
harmful as well as helpful. Bergin documented the presence of a deterioration
effect as early as 1966 and pursued it in a large-scale review published in 1977
(Lambert, Bergin, & Collins, 1977) that attempted to examine the breadth
of the findings across school-based psychotherapies and treatment modalities
(e.g., group, family), actual deterioration rates, and the possible mechanisms
responsible for such negative effects, including both client and therapist char-
acteristics. His contributions inspired others to investigate and explore simi-
lar phenomena in areas of psychotherapy that had never before been subjected
to empirical scrutiny, such as couple and family therapy (e.g., Gurman, 1973;
Gurman & Kniskern, 1978).
After publishing his 1966 article, Bergin received considerable mail from
patients as well as therapists, detailing injuries that seemed to have resulted
from treatment and more specifically from the behavior and attitudes of ther-
apists. Although cautious in his judgment about the reliability of such reports,
Bergin noted that most came from clients who felt mistreated by their thera-
pists but had found subsequent help and were functioning well at the time they
contacted him. This anecdotal information, along with research accounts of
the phenomenon, led Bergin to the conclusion that client deterioration was
ALLEN E. BERGIN 105

most closely linked to therapist attitudes and in-session interpersonal behav-
iors rather than the misuse of specific theory-based interventions, thereby pre-
saging important contemporary work on therapist (vs. technique) factors in
treatment outcome by about 3 decades. He also noted that negative therapist
attitudes interacted with and were especially harmful with particularly vul-
nerable clients, a clinically important finding later corroborated in the realm
of family therapy (Gurman & Kniskern, 1978).
Clearly, in his mind, the problem of deterioration was most likely a fail-
ure in the personal adjustment of, and lack of benevolence in, therapists. The
problem this unmasked was, then, the common failure of graduate programs
to select wise and goodhearted people and their failure to make difficult deci-
sions about trainees who needed to be carefully monitored in their clinical
work or perhaps even dismissed from their programs after accumulating evi-
dence made it clear that they were responsible for an undue proportion of
failed therapy cases, some with negative effects. With regard to deterioration,
little evidence presented itself that failures in training for the technical
aspects of interventions were an important area for concern.
Bergin was also an advocate of the importance of variability in a more
general and statistical sense. He believed that what was hidden by a mean
could be the most important information in need of assimilation. He at once
advocated the necessity of reductionism:
Some critics argue that to break down, isolate, and extract variables from
the therapeutic context is to drastically modify and underestimate the
complexity of the phenomena under study. I feel this is irrelevant and
unnecessarily inhibiting because (a) no science or applied science has
ever progressed without simplifying. (1971, p. 254)
and at the same time he advocated the experimental case study approach and
said,
For these reasons, I am generally distrustful of group-based multifactorial
studies, and of statistical operations that are associated with them. The
results are too often of no practical use because they amount to nothing
more than abstractions on top of confusion. (1971, p. 255)
His early advocacy (4 decades ago) of both quantitative and qualitative meth-
ods foreshadowed current debates about the relative value of these divergent
procedures.
As in many other ways, Bergin, when serving as students’ dissertation
advisor, eschewed “fancy” statistical techniques to reveal treatment effects
that really mattered and maintained that simple line graphs should be able to
show what he called “WOW!-effects.” At TC, he strongly advocated for clin-
ical students who had the courage to do “nontraditional” research, such as
empirical single-case studies and theoretical dissertations, inevitably ending

up as the primary advisor of students who wanted to break new dissertation
ground.
The Effectiveness of Paraprofessionals
Reviews of the causes of client deterioration and the general effects of

psychotherapy also led Bergin to examine the surprisingly positive outcomes
that resulted when carefully selected laypeople offered treatments. This work
left little doubt in his mind that the personal attributes of providers were cen-
tral in whatever led to positive outcomes in clients, regardless of their theo-
retical orientation. His work certainly anticipated today’s debates between
those advocating evidence-based practices in the form of systems of psycho-
therapy, versus an emphasis on common curative factors.
While always remaining true to the data, whether they led to a conclusion
about therapy’s overall effectiveness or to a conclusion about the negative
effects produced by some therapists, Bergin was hardly neutral in his view that
proponents of therapy models are ethically obligated to show acceptable evi-
dence of the efficacy and effectiveness of their preferred methods. About a
decade after the publication of the first edition of the Handbook, Bergin
remarked:
It is one of the anomalies of the behavioral and psychiatric sciences that
methods of intervention can still be invented, used and paid for by the
public without a shred of standard empirical evidence to demonstrate
efficacy and absence of harmful effects. This kind of proliferation is a
professional scandal. (Personal communication, 1980, from Bergin to
Gurman)
Religious Values, Psychotherapy, and Mental Health
Perhaps it is not surprising that during the latter half of his career,
Bergin increasingly began to turn his professional attention to broader social
issues that were pertinent to the science and practice of psychotherapy,
including the topics of values and psychotherapy, religion and mental health,
and spirituality and psychotherapy. Bergin had long been interested in such
issues. As a young adult at the Massachusetts Institute of Technology and
then at Reed College, in Portland, Oregon, Bergin considered himself agnos-
tic regarding matters of faith. Although he respected the scientific enterprise
and thrived on the rigor of empirical inquiry, Bergin found himself person-
ally unsatisfied by the deterministic and reductionistic assumptions of the
natural and behavioral sciences. After a couple of years of intense question-
ing and searching, Bergin’s spiritual quest led him to enroll at Brigham Young
University and to convert to the Church of Jesus Christ of Latter-day Saints
ALLEN E. BERGIN 107

(LDS). During the remaining years of his undergraduate work at Brigham
Young University, his graduate studies at Stanford University, and his post-
doctoral experience with Carl Rogers at the University Wisconsin Medical
School Psychiatric Institute, Bergin grew increasingly aware of and concerned
about the alienation and conflicts that then existed between psychology and
religious tradition. During his years as a professor at Columbia University, this
awareness and concern continued to grow, and with increasing frequency he
began to raise questions in professional contexts about value and moral issues
as they pertained to psychotherapy (Bergin, 1991). While at Columbia Uni-
versity, Bergin served in various lay leadership positions within his church,
including several years as the bishop of a local LDS congregation, where he
frequently used the resources of his religious community to assist members of
his congregation who were struggling with various emotional and relation-
ship problems.
Bergin’s first major publication about religion and psychotherapy,
“Psychotherapy and Religious Values,” was published in 1980 in the Journal
of Consulting and Clinical Psychology (Bergin, 1980a) and previewed many of
the scholarly themes he would pursue during the remainder of his career. In
the article, Bergin documented the historical and philosophical alienation
of religion and psychology and its effects on the practice of psychotherapy.
He made a number of other points about psychotherapy and religious values.
The majority of mainstream psychotherapists, he maintained, have adopted
views of human nature (i.e., naturalistic and deterministic ones) that conflict
with theistic, spiritual views. The values and therapeutic goals (i.e., clinical–
humanistic ones) of most psychotherapists often conflict with those of their
religious and spiritually oriented clients. He argued that by not being open
about the values and goals that guide their therapeutic work, mainstream
psychotherapists may implicitly impose alien values frameworks on their
religious clients. As a result, he warned, many psychotherapists may be guilty
of engaging in culturally biased and insensitive therapy with theistic religious
clients by pursuing therapeutic goals that conflict with their clients’ spiritual
beliefs and values; not all clinical–humanistic beliefs and values are healthy
and socially benevolent. Bergin maintained that there are many healthy and
socially benevolent theistic religious values, and the psychotherapy profes-
sion would be enriched by the incorporation of these values into its theories
and practices. Mainstream psychotherapists, he believed, have for too long
been biased against religion and have excluded religious and spiritual perspec-
tives from their theories and work.
The article, which became a citation classic, generated intense interest,
enthusiasm, and controversy in the psychology profession. In the subsequent
issue of the same journal, responses to Bergin’s article by Albert Ellis (1980)
and Gary Walls (1980) were published along with a rejoinder by Bergin

(1980b). Albert Ellis objected to Bergin’s portrayal of the views of probabilis-
tic atheist clinicians like himself and clarified his position on a number of
value issues such as moral relativism, sexuality, and marriage and family. Ellis
(1980) also hypothesized that “devout, orthodox, or dogmatic religion (or
what might be called religiosity) is significantly correlated with emotional dis-
turbance” (p. 637). In his rejoinder, Bergin (1980b) stated, “Although I
believe that religion can be powerfully benevolent, I have to agree with Ellis
and Walls that it is not always a positive influence. Religion is diverse and
therefore its effects are diverse.” Consistent with the commitment to empir-
ical research that characterized his work on psychotherapy outcomes, Bergin
also discussed the research literature concerning religion and mental health,
characterizing it as “contradictory and ambiguous” (p. 643).
Following the publication of his 1980 article, Bergin launched a series
of empirical studies concerning religion and mental health, including a meta-
analysis of the existing research literature on this topic., During the next
2 decades, Bergin’s scholarship increasingly focused on issues concerning reli-
gion and mental health and spirituality and psychotherapy, although he con-
tinued to make significant contributions to the literature concerning the
outcomes of psychotherapy.
ADDITIONAL ACHIEVEMENTS
Bergin was among those who founded the Society for Psychotherapy
Research (SPR), serving as its fifth president, 1974–1975, and he organized its
first international meeting (London, 1975). SPR, like the Handbook, was ded-
icated to following the evidence wherever it led. Bergin’s work always embod-
ied and exemplified the attitude of his early mentor Rogers, who emphasized
that “the facts are always friendly, every bit of evidence one can acquire . . .
leads one that much closer to what is true” (Rogers, 1961, p. 26). Always
eager to spread the word about the importance and excitement of investigat-
ing psychotherapy, Bergin attracted many of his 1971 clinical students to the
Second International Annual Meeting of SPR in Saddle Brook, New Jersey,
across the Hudson River from Manhattan. During the latter years of his
career, despite significant health challenges, Bergin remained productive in
scholarship, editing the fourth edition of the Handbook of Psychotherapy and
Behavior Change and coauthoring and coediting two other volumes about spir-
ituality and psychotherapy (Richards & Bergin, 1997, 2000) in which a vari-
ety of authors made suggestions for more effective, culturally sensitive practices
for religious clients from a diversity of Western and Eastern spiritual tradi-
tions. Bergin remained open to diverse views.
ALLEN E. BERGIN 109

REFERENCES
Bergin, A. E. (1966). Some implications of psychotherapy research for therapeutic

practice. Journal of Abnormal Psychology, 71, 235–246. doi:10.1037/h0023577
S. L. Garfield (Eds.), Handbook of psychotherapy & behavior change (pp. 217–270).
Bergin, A. E. (1980a). Psychotherapy and religious values. Journal of Consulting and
Bergin, A. E. (1980b). Religious and humanistic values: A reply to Ellis and Walls.
006X.48.5.642
Bergin, A. E. (1991). Values and religious issues in psychotherapy and mental health.
Bergin, A. E., & Garfield, S. L. (1971). Handbook of psychotherapy & behavior change.
Bergin, A. E., & Garfield, S. L. (Eds.). (1994). Handbook of psychotherapy and behav-
ior change (4th ed.). New York, NY: Wiley.
Bergin, A. E., & Strupp, H. H. (1972). Changing frontiers in the science of psychotherapy.
Chicago, IL: Aldine.
Ellis, A. (1980). Psychotherapy and atheistic values: A response to A. E. Bergin’s
“Psychotherapy and Religious Values.” Journal of Consulting and Clinical Psychol-
ogy, 48, 635–639. doi:10.1037/0022-006X.48.5.635
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Con-
sulting Psychology, 16, 319–324. doi:10.1037/h0063633
Garfield, S. L., & Bergin, A. E. (1978). Handbook of psychotherapy and behavior change
(2nd ed.). New York, NY: Wiley.
Gurman, A. S. (1973). The effects and effectiveness of marital therapy: A review
of outcome research. Family Process, 12, 145–170. doi:10.1111/j.1545-5300.
1973.00145.x
Gurman, A. S., & Kniskern, D. P. (1978). Deterioration in marital and family therapy:
Empirical, clinical and conceptual issues. Family Process, 17, 3–20. doi:10.1111/
j.1545-5300.1978.00003.x
Lambert, M. J., Bergin, A. E., & Collins, J. L. (1977). Therapist-induced deteriora-
tion. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook
of research (pp. 452–481). New York, NY: Pergamon.
Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Richards, P. S., & Bergin, A. E. (Eds.). (2000). Handbook of psychotherapy and religious
diversity. Washington, DC: American Psychological Association.
Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin.

Strupp, H. H., & Bergin, A. E. (1969a). Some empirical and conceptual bases for coor-
dinated research in psychotherapy: A critical review of issues, trends and evi-
dence. International Journal of Psychiatry, 7, 18–90.
Strupp, H. H., &, & Bergin, A. E. (1969b). Critical evaluations of: Some empirical
and conceptual bases for coordinated research in psychotherapy: Critical review
of issues, trends and evidence. International Journal of Psychiatry, 7, 116–121.
Walls, G. (1980). Values and psychotherapy: A comment on “Psychotherapy and
Religious Values.” Journal of Consulting and Clinical Psychology, 48, 640–641.
doi:10.1037/0022-006X.48.5.640
ALLEN E. BERGIN 111

10
KLAUS GRAWE: ON A CONSTANT
QUEST FOR A TRULY INTEGRATIVE
AND RESEARCH-BASED
PSYCHOTHERAPY
FRANZ CASPAR AND MARTIN GROSSE HOLTFORTH
Klaus Grawe died unexpectedly from a heart attack, in Zürich in July

2005. He may be seen as the best-known and most influential psychotherapy
researcher in Continental Europe. He had a unique way of being fascinated
by psychotherapy and psychotherapy research, of using basic psychological
and later neurobiological models to advance psychotherapy, and of convey-
ing his concepts to colleagues in an engaging way. In line with developing
concepts emphasizing the interpersonal aspects of psychotherapy, he was a
very caring human being.
He was a fascinated reader of psychodynamic literature until he asked
himself, “Where do they [the authors] know this from?” He then rigorously
searched for empirically supported concepts, in an open way that emphasized
their use for clinical practice. He was also always eager to argue with those
who hindered scientific progress rather than contributing to it. Although not
all colleagues were happy with the criticism he leveled against some claims
by psychotherapy approaches that he considered empirically unjustified,
European as well as international psychotherapy research has profited enor-
mously from his unique spirit.
113
MAJOR CONTRIBUTIONS
Mindful of the inherent incompleteness of any summary of Klaus Grawe’s

contributions to psychotherapy research, we believe that his contribution
reflects five major qualities as the expression of one spirit. First, Klaus Grawe
was a builder, as demonstrated by the establishment of the clinics in Bern and
Zurich, as well as a postgraduate program for psychotherapy training. Second,
he was an innovator in various arenas. Empirically, he developed and tested new
approaches to therapy (based on Plan Analysis and consistency theory). Con-
ceptually, he enriched our understanding of the process of change via concepts
borrowed from traditions as diverse as Piaget and neuroscience. Clinically, he
was a pioneer on outcomes assessment and feedback of assessment results to
therapists and patients. Third, he was also a leader in terms of policy (as demon-
strated by his work for the German legislature) and a paradigm shift within
research (as shown by his contribution to the second generation of approaches
to psychotherapy). Fourth, he was also a collaborator, working with many peo-
ple to change the way psychotherapy is investigated, practiced, conceived, and
taught. Fifth, he was an outstanding scholar, having provided great summaries
of the field (via meta-analysis; a handbook chapter on process–outcome
research; and publication of two conceptual books, Psychological Therapy [2004]
and Neuropsychotherapy [2006]) and fruitful heuristics for future conceptual and
empirical developments (e.g., the identification of four mechanisms of change,
in a presidential address in 1997). In sum, all his accomplishments were guided
by an integrative spirit, which manifested itself in different forms:
䡲 theoretical integration (as in his combination of learning and
motivation principles in 1980, and his consistency theory
later on);
䡲 integration of process and outcome findings (as reflected, for
example, in the trials published in 1990 and after his death;
Grosse Holtforth, Grawe, Fries, & Znoj, 2008);
䡲 integration of basic (psychopathology, cognitive, and neuro-
science) and applied sciences;
䡲 and, of course, integration of research and practice (as reflected
in his Therapy Spectrum Analysis, as well as in the 2004 and
2007 books).
EARLY BEGINNINGS
Klaus Grawe was born in 1943 in Wilster (Northern Germany), during

a time of evacuation, fleeing the bombs on his family’s home town of Ham-
burg. He went to school in Hamburg and studied psychology in Hamburg and
114 CASPAR AND HOLTFORTH

Freiburg im Breisgau, receiving his diploma in 1968 in Hamburg. It was
mainly his mother to whom he owed the firm belief that, although sometimes
hard, life is fundamentally benign. After an accident that impaired one of his
eyes at a young age, he had much time to reflect and to develop strength doing
so. This did not hamper his amazingly energetic presence or his joie de vivre.
On the contrary!
His dissertation on the differential effects of behavior and client-centered
therapy with anxiety patients followed in 1976, and his habilitation, the
German degree qualifying for a tenured position, in 1979. He cofounded the
multiapproach psychotherapy ward at the Eppendorf University psychiatric
hospital in Hamburg and worked there for 11 years. This was a decisive time
for him: In the concrete everyday work with patients he experienced the
limits of traditional behavior therapy in particular, and of traditional psycho-
therapy approaches in general. More specifically, he noticed that many patients
were not able to concentrate on what they were supposed to do to reduce their
symptoms. Instead, they were engaged in interactional struggles with their
therapists and at times also with other therapy group members.
Although skillful in using traditional behavior analyses as a means for
understanding the functioning of patients, Grawe was convinced that a dif-
ferent approach was needed to understand the often strange behavior of
patients in the therapy session: One needed to understand the structure of
patients’ motives better. He found useful the “Plan” concept by Miller,
Galanter, and Pribram (1960), which they had developed in the context of
general psychology. The structure of Plans (written in the upper case, as sug-
gested by Miller et al., to distinguish the term from its everyday meaning) is
the total of instrumental strategies serving our basic needs. Individual Plan
Analyses of patients allow a deeper understanding of how a reinforcer or pun-
ishment meet the individual motivational structure.
In 1979, he moved to Bern, along with with his young assistant Franz
Caspar, to fill the newly installed position of the chair for clinical psychology,
and he remained in this position until his death.
ACCOMPLISHMENTS
In Bern, a new era in his activities began, as he now had better resources
for the realization of many of his ideas. A major postulate was to allow students
to integrate practice with the theoretical knowledge acquired at the univer-
sity, very much in the sense of the Boulder scientist–practitioner model. With
his colleagues, Grawe installed an outpatient clinic in which qualified stu-
dents had the opportunity to practice psychotherapy with patients. At this
Praxisstelle he and his coworkers ran a comparative randomized study, in
KLAUS GRAWE 115

which treatments following different forms of case formulation were compared.
Although the therapeutic procedure was not manualized, it was prescribed, in
that it needed to be explicitly and logically derived from one of three forms of
case formulations: (a) classical functional behavior analysis, (b) “vertical”
behavior analysis, or (c) client-centered therapy (with no explicit form of case
formulation). In a classical functional behavior analysis, stimuli, reactions, con-
sequences, etc., are analyzed in the sense of temporal “horizontal” chains. Clas-
sical (i.e., Which stimulus triggers which reaction?) as well as instrumental/
operant (i.e., Which reinforcer makes a behavior more frequent and/or
intense?) conditioning, along with concepts such as model learning, are used
to explain the development and maintenance or generalization of behavior.
Vertical behavior analyses added a vertical dimension to the classical horizon-
tal behavior analyses by analyzing patient motives following the Plan approach.
Vertical refers to the hierarchical structure of Plans as proposed by Miller et al.
(1960), in which concrete behaviors are allocated on the lowest level, general
human needs on the top level, and the individual instrumental strategies in
between. The criterion for the hierarchy is the instrumental function: Among
connected elements, the higher represents the purpose or goal of the lower,
which in turn represents the means for the higher element (Caspar, 2007).
In this project, the demand of specifying the therapeutic procedure was
acknowledged, but instead of manualizing and measuring adherence, the
therapists had more leeway for individualizing the procedure. By extensively
describing the actual process from the perspectives of patient, therapist, and
independent observers, the therapists made the procedure transparent. Find-
ings of the trial were that the vertical behavior analysis condition outperformed
the other conditions regarding outcome, but only in a subset of the criteria
such as individually defined goals (goal attainment scaling; Kiresuk, Smith,
& Cardillo, 1994). However in process measures, this form of therapy showed
overwhelming superiority on a wide range of variables. Patients felt much
better understood by their therapists, more motivated for change, etc. We
were to some extent afraid that therapists engaged in reflecting the patients’
Plan Structure could lose immediate contact with what the patient is experi-
encing or somehow convey that much of what they are thinking is being
withheld from the patient. To be sure, we formulated items for the patient
session questionnaire to assess exactly such potential side effects. As a matter
of fact, and surprising to us, patients in the Plan Analysis condition felt even
less than in the other conditions that their therapists were thinking things
that they did not express, and they found even more that their therapists did
justice to their emotions.
Grawe did not perceive the lack of strong superiority in outcome mea-
sures as just another “Dodo bird” result but felt motivated to trace many of the
differential effects in detail. For example, submissive patients profited more

from traditional behavior therapy, whereas more autonomy-seeking patients
profited more from client-centered therapy. Empirically identifying such an
aptitude–treatment interaction corresponds well with the frequently voiced
need for selecting specific kinds of treatments for particular patients (Beutler
& Clarkin, 1990; Beutler et al., 2003). The success of patients in the vertical
behavior analysis condition depended much less on patient variables, suggest-
ing that therapists in this condition were better able to adapt to the character-
istics of specific patients (Grawe, Caspar, & Ambühl, 1990). This is much in
line with what Bill Stiles (Stiles, Honos-Webb, & Surko, 1998) later desig-
nated therapist responsiveness. For example, with a patient deprived in his or
her narcissistic needs, a therapist would invest much to satisfy such needs in a
noncontingent way that does not reinforce problematic means used by the
patient to force others to satisfy him narcissistically. A therapist would thus
actively seek nonproblematic, positive patient properties and behaviors to
which he or she can relate in a positive, acknowledging way. With a rather
schizotypic patient, a therapist would rather avoid offering too much threat-
ening closeness but would reassure the patient by giving him or her all the dis-
tance needed to feel safe. The idea is that a patient can engage much better in
the process of change once he or she is convinced that the therapist represents
no threat to his or her most important needs, but respects and furthers them.
Along with conducting this study and building the clinical psychology
section at his department, Grawe represented psychotherapy research in a
committee of the German government preparing the new psychotherapy law
(Meyer, Richter, Grawe, Schulenburg, & Schulte, 1991). Unfortunately,
against his clear intention, this cemented rather than challenged the school-
oriented approach to psychotherapy. The new psychotherapy legislation
sided with the efficacy of therapeutic techniques or approaches, although
Grawe kept emphasizing the importance of other factors, such as the thera-
peutic relationship or a general orientation toward the patient’s strengths
(resources).
At the level of theoretical concepts, he elaborated his Schema Theory,
a concept that referred to Piaget (1977) in several ways and offered elements
related to the development of psychopathology as well as to the process of
psychotherapy in a way independent from a specific school of psychotherapy.
Influenced by developments in empirical psychology at the time, Klaus Grawe
assimilated the schema concept with his motivation-based theoretical and
therapeutic approach. By building this theoretical bridge Grawe hoped to
make concepts and findings from various subdisciplines of psychology usable
for the advancement of psychotherapy research and practice. Attractive fea-
tures of the schema concept, according to Grawe, were that it is nonstatic,
that is, it is well suited to describe therapeutic change, and that it addresses
emotional aspects of patient functioning and change.
KLAUS GRAWE 117

During this time, in the late 1980s, an intense cross-theoretical collab-
oration with the German psychoanalyst Horst Kächele (see Chapter 21, this
volume) had been established. An important part of it took place in the
framework of the PEP (Psychotherapeutisches Einzelfall (Single Case) Prozess
Forschung) research group, in which two cases, one from Ulm and one from
Bern, were intensely studied by a great number of colleagues engaged in
process research in the German-speaking countries. Meetings among others
in Bern and in Krattigen above the Lake of Thun are memorable in terms of
research (of course!) but also in terms of personal encounters, landscape, and
gastronomy.
In 1992, Klaus Grawe founded a postgraduate psychotherapy training
program. The legal situation in Switzerland had changed in such a way that
a 4-year postgraduate training was required to acquire the title of “psycho-
therapist” and the right to practice. Consequently, no training elements before
and during master’s level training in psychology counted, and students lost
interest in psychotherapy practice during master’s level training. Limited
resources did not allow for engaging in both extensive introductions of mas-
ter’s students into practice, as well as running a new postgraduate training, so
the former was terminated in favor of the latter. In 1999, Grawe added a train-
ing facility in Zürich, which was linked with an outpatient clinic codirected
with his second wife since 1987, Mariann Grawe-Gerber.
While the aforementioned comparative study was running with a strong
emphasis on process–outcome research, on which Grawe set his heart, he
also engaged in a comparison of the outcomes of different psychotherapy
approaches. In 1994, he published, along with his doctoral students Bernauer
and Donati, his meta-analysis Psychotherapie im Wandel. Von der Konfession zur
Profession [Psychotherapy in Transition: From Confession to Profession].
He experienced the compilation of such an immense body of material
(which he largely did at night) as torture, but he felt an obligation to come
up with a broad and fair comparison. While some therapeutic orientations
failed completely in the empirical legitimization of their claims, psycho-
analysis was credited for some evidence. Reactions from the psychodynamic
camp were very strong, and his evidence was criticized for not supporting
what members from this camp saw as the clearly superior and only sufficiently
“deep” approach. In one incident at an event in Munich where he had been
invited to present his book, Grawe (who was tall and never fearful) felt even
physically threatened. He was deeply shocked by this experience and saw
himself thrown back from the era of enlightenment to the medieval age.
Although he did not consider conducting meta-analyses on psychotherapy
outcome the most “thrilling” academic activity, he was strongly identified
with this research by many colleagues who disliked his conclusions and did
not know about his contributions in process research.

These strong reactions and the lack of an empirically informed, open
search for the best procedure to help difficult patients stimulated articles pos-
tulating a “second generation” of approaches to psychotherapy (Grawe, 1995).
These second-generation approaches would acknowledge the merits of the
first-generation approaches, that is, the original approaches developed by the
founders of the traditional schools of psychotherapy. In addition, second-
generation approches would seek to overcome the limits of first-generation
approaches by incorporating all relevant empirical findings related to the
domain for which they claimed validity (such as the treatment of a particular
disorder). At the same time, they would also incorporate findings incompati-
ble with the conceptual point of departure. As empirical findings are develop-
ing continuously, the search for the most adequate concepts is by definition a
never-ending process.
Anticipating empirical and clinical work that is predominant in the cur-
rent field (Kraus, Wolf, & Castonguay, 2006; Lambert, 2007), Klaus Grawe
also believed strongly in the value of ongoing feedback on the therapeutic
process. To be realistic and meaningful, original data needed to be presented
in a way that enabled therapists to see conspicuous information immediately.
This applies equally to data from pretherapy assessments such as the Symp-
tom Checklist-90-R or Beck Depression Inventory: Grawe’s idea was to hold
individual data against the background of a well-known reference group
instead of an anonymous and abstract norm sample. For example, one might
compare a client’s SCL-90 scores with those of all patients who have been
seen in the same outpatient clinic during the past 5 years. In this way, thera-
pists can obtain immediately and concretely meaningful information if they
know that on a particular criterion, a patient scores more than one standard
deviation higher than the average of the reference group with which a ther-
apist is familiar. To hold individual data against such a background was des-
ignated figuration analysis by Grawe. In addition, a representation in a graphic
form instead of numbers in tables helps to screen out important information
quickly and easily.
In his influential 1997 article based on his 1996 Society for Psycho-
therapy Research (SPR) presidential address, Klaus Grawe formulated a vision
of a truly research-informed psychotherapy that would flexibly use all empiri-
cally validated mechanisms of change in psychotherapy. Based on available
process and outcome research (Orlinsky, Grawe, & Parks, 1994), Grawe iden-
tified four such mechanisms of change: (a) mastery/coping, (b) clarification of
meaning, (c) problem actuation, and (d) resource activation. These general
change mechanisms were intended to cover the full spectrum of potential
change processes in psychotherapy. To bridge the gap between psychotherapy
process research and psychotherapy practice, Klaus Grawe and coworkers
incrementally developed the Therapy Spectrum Analysis (TSA; German:
KLAUS GRAWE 119

Wirkfaktorenanalyse [WIFA]; Smith & Grawe, 2003) as a standardized coding
tool for the realization of these therapeutic change mechanisms within individ-
ual therapy sessions. In one example of productively using the TSA, Smith and
Grawe (2005) analyzed the results of more than 700 therapy sessions with more
than 100 patients. They formulated empirically validated heuristics that spec-
ified a mixture of resource- and problem-focused interventions suited to the dif-
ferent phases of therapy and guided the therapist’s session-to-session decisions
for the continual adaptation of treatment procedures. To give an example based
on statistically derived rules predicting session productivity Smith and Grawe
(2005) formulated the following recommendations:
In the first few sessions of therapy, when the focus is on the analysis of the
patient’s problems, the therapist must pay special attention to acknowl-
edging and encouraging the patient’s resources and strengths. In the mid-
dle of therapy, when the focus is largely on the emotionally actuated
problems of the patient, the therapist should encourage the patient to
make an active contribution towards problem discussion. Towards the end
of therapy, when the focus moves away from the discussion of emotion-
ally actuated problems, the therapist should emphasize the resources of the
patient and the achieved changes. (p. 121)
Further underscoring the importance of using the patient’s strengths in
a subsequent study, Gassmann and Grawe (2006) demonstrated that problem
activation could unfold its therapeutic potential only when it was combined
with thorough resource activation.
In 1998, Klaus Grawe summarized his current conception of psycho-
therapy in Psychological Therapy (published in English in 2004), written as a
dialogue between a practicing therapist, a research psychologist, and a therapy
researcher. After laying out the facets of therapeutic change, he related the
mechanisms of action in psychotherapy to basic psychological concepts and
formulated a psychological theory of psychotherapy (designated consistency
theory) that should be continually developed and empirically updated. He
gave suggestions as to how psychotherapy training and practice could be
improved on the basis of consistency theory. On the basis of the central
assumption that inconsistency in psychological functioning contributes to
the development and maintenance of psychological disorders, he designed a
randomized controlled trial that tested the hypothesis that the level of incon-
sistency differentially predicts the outcome in various forms of psycho-
therapy. In this trial, a condition that implemented the practical implications
of consistency theory in an integrative psychotherapy was compared with a
form of cognitive–behavioral therapy. At the level of change mechanisms, the
integrative condition combined interventions fostering all four of the
previously mentioned mechanisms of change on the basis of individual
case formulations. While the two conditions demonstrated equal outcomes

after 20 sessions, differential effects were observed for the level of avoidance
motivation as a measure of inconsistency (i.e., patients with higher levels of
avoidance goals fared better in the integrative condition; Grosse Holtforth,
Grawe, Fries, & Znoj, 2008).
In his most recent work, Klaus Grawe focused on the integration of the
fields of neurobiology and brain sciences with clinical psychology and psycho-
therapy and called this area “neuropsychotherapy” (Grawe, 2006). He attempted
to bridge the gaps between the neurosciences, the understanding of psycho-
logical disorders outlined in consistency theory, and psychotherapy prac-
tice by providing necessary know-how for mental health professionals as it
connects the findings of modern neuroscience to the insights of psycho-
therapy. Klaus Grawe was convinced that psychotherapy could be even more
effective when it is grounded in a neuroscientific approach.
OTHER CONTRIBUTIONS
In addition to his scholastic and research contributions, Klaus Grawe

contributed significantly to the growth of psychotherapy, by serving many
roles in professional organizations and mentoring many generations of scien-
tists and practitioners. Among his many professional activities he counted the
executive committee and presidency of SPR and the executive committee of
the German Society for Psychology (DGPs). He was editor of the Zeitschrift
für Klinische Psychologie und Psychotherapie and Psychotherapy Research, inter
alia, and cofounded a series ( Fortschritte der Psychotherapie [Progress in Psycho-
therapy]) of state-of-the-art psychotherapy manuals.
His doctoral students are countless. The following researchers accom-
plished their habilitations with him (in alphabetical order): Franz Caspar,
Martin Grosse Holtforth, Wolfgang Lutz, Wolfgang Tschacher, and Hansjörg
Znoj.
CONCLUSION
Klaus Grawe was a prolific academic writer who published more than
150 articles and book chapters, as well as five books. Although he elaborated
his view of mental problems and psychotherapy in many publications, his
emphasis was on the continuous development of knowledge, rather than on
the elucidation of particular concepts. For example, the approach of general
psychotherapy that he developed remained for him a vehicle or template for
research, rather than a specific theory in competition with the traditional
schools of psychotherapy.
KLAUS GRAWE 121

In his quest for better understanding psychotherapy, he continuously
searched basic psychology and neighboring fields for useful, empirically
grounded concepts, and he was in this sense grounded in empirical science.
At the same time, he cultivated a solid sense for what is important in psycho-
therapy practice. He strongly advocated adapting research methods and designs
to particular research questions instead of excluding practically important
questions from research because of extrascientific considerations. This basic
conviction contributed to an ongoing strong interest in his work among prac-
titioners and to reducing the science–practice gap.
While he adhered to some principles, such as empirical grounding of
psychotherapy practice and not limiting oneself by mind-stopping limitations
of specific approaches (traditionally: the schools of psychotherapy), he used to
question and revise concepts in a never-ending process. In this sense, perhaps
his biggest legacy is to have conceptually opened our minds while remaining
strictly empirical.
REFERENCES
Beutler, L. E., & Clarkin, J. (1990). Systematic treatment selection: Toward targeted
therapeutic interventions. New York, NY: Brunner/Mazel.
Beutler, L. E., Moleiro, C., Malik, M., Harwood, T. M., Romanelli, R., Gallagher-
Thompson, D., & Thompson, L. (2003). A comparison of the Dodo, EST, and
ATI indicators among co-morbid stimulant dependent, depressed patients. Clin-
ical Psychology & Psychotherapy, 10, 69–85. doi:10.1002/cpp.354
Caspar, F. (2007). Plan Analysis. In T. Eells (Ed.), Handbook of psychotherapeutic case
formulations (2nd ed., pp. 251–289). New York, NY: Guilford.
Gassmann, D., & Grawe, D. (2006). General change mechanisms: The relation
between problem activation and resource activation in successful and unsuccess-
ful therapeutic interactions. Clinical Psychology & Psychotherapy, 13(1), 1–11.
doi:10.1002/cpp.442
Grawe, K. (1995). Grundriss einer Allgemeinen Psychotherapie [Blueprint of a gen-
eral psychotherapy]. Psychotherapeut, 40, 130–145.
Grawe, K. (1997). Research informed psychotherapy. Psychotherapy Research, 1, 1–19.
doi:10.1080/10503309112331334001
Grawe, K. (2004). Psychological therapy. Toronto, ON: Hogrefe & Huber.
Grawe, K. (2006). Neuropsychotherapy. How the neurosciences can inform effective
psychotherapy. Mahwah, NJ: Erlbaum.
Grawe, K., Donati, R., & Bernauer, F. (1994). Psychotherapie im Wandel. Von der
Konfession zur Profession [Psychotherapy in transition. From confession to
profession]. Göttingen, Germany: Hogrefe.

Grawe, K., Caspar, F., & Ambühl, H. (1990). Die Berner Therapievergleichsstudie
[The Bern psychotherapy trial]. Zeitschrift für Klinische Psychologie, 19, 294–315.
Grosse Holtforth, M., Grawe, K., Fries, A., & Znoj, H. (2008). Inkonsistenz als dif-
ferentielles Indikationskriterium in der Psychotherapie–eine randomisierte
kontrollierte Studie [Inconsistency as a criterion for differential indication in
psychotherapy]. Zeitschrift für Klinische Psychologie und Psychotherapie, 37, 103–111.
doi:10.1026/1616-3443.37.2.103
Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal attainment scaling: Applications,
theory, and measurement. Hillsdale, NJ: Erlbaum.
Kraus, D., Wolf, A., & Castonguay, L. G. (2006). The outcome assistant: A kinder
philosophy to the management of outcome. Psychotherapy Bulletin, 41, 23–31.
Lambert, M. J. (2007). Presidential address: What we have learned from a decade of
research aimed at improving psychotherapy outcome in routine care. Psychother-
apy Research, 17(1), 1–14.
Meyer, A.-E., Richter, R., Grawe, K., Schulenburg, J.-M., & Schulte, B. (1991).
Forschungsgutachten zu Fragen eines Psychotherapeutengesetzes im Auftrag des
Bundesministeriums für Gesundheit [Experts’ report for a psychotherapy law].
Universitätskrankenhaus Eppendorf, Hamburg, Germany.
Miller, G. A., Galanter, E., & Pribram, K. A. (1960). Plans and the structure of
behavior. New York, NY: Holt, Rinehart &Winston. doi:10.1037/10039-000
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in
psychotherapy—noch einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook
of psychotherapy and behavior change. New York, NY: Wiley.
Piaget, J. (1977). The development of thought: Equilibration of cognitive structures.
Oxford, England: Viking.
Smith, E., & Grawe, K. (2003). What makes psychotherapy sessions productive? A
new approach to bridging the gap between process research and practice. Clini-
cal Psychology & Psychotherapy, 10, 275–285. doi:10.1002/cpp.377
Smith, E. C. & Grawe, K. (2005). Which therapeutic mechanisms work when? A
step towards the formulation of empirically validated guidelines for therapists’
session-to-session decisions. Clinical Psychology & Psychotherapy, 12, 112–123.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psycho-
therapy. Clinical Psychology: Science and Practice, 5, 439–458.
KLAUS GRAWE 123

III
HOW DOES
PSYCHOTHERAPY WORK?
A. THERAPIST
CONTRIBUTIONS
11
MARVIN R. GOLDFRIED: PIONEERING
SPIRIT AND INTEGRATIVE FORCE
LOUIS G. CASTONGUAY AND JOHN C. NORCROSS
Marvin R. Goldfried has continually advanced the science and practice

of psychotherapy throughout his illustrious 30-year career as a psychotherapy
process–outcome researcher and cognitive–behavior therapy (CBT) practi-
tioner. To this end, he has originated or contributed to the development of
at least four pivotal ideas that have significantly shaped the field of psycho-
therapy research. First, in the early 1970s, Goldfried became a highly
regarded proponent of CBT and published widely in the psychotherapy
research literature. Next, he played a key role in the establishment of psycho-
therapy integration during the 1980s. Continuing within the integrative
tradition, he made a third, pivotal contribution to psychotherapy practice,
research, and training when he spearheaded the integration of lesbian, gay,
and bisexual (LGB) issues into mainstream psychology, in the early 2000s.
And finally, throughout the course of his career, Goldfried has made signifi-
cant contributions to the study of the therapy process by undertaking the dif-
ficult yet indispensable task of identifying key factors that facilitate client
improvement.
129
EARLY BEGINNINGS
Marvin Goldfried was born in Brooklyn in 1936 to parents who had fled
Eastern Europe in the early 1900s. As the first person in his family to go beyond
high school, he attended Brooklyn College and majored in psychology. A num-
ber of faculty members in the Psychology Department were active, empirical
researchers, and as an undergraduate he was encouraged by several professors to
attend graduate school. Maintaining an active, empirically based research pro-
gram would become a sustaining theme in his future academic career.
Goldfried received his graduate education in clinical psychology at the
University of Buffalo, now known as the State University of New York at
Buffalo. While projective testing and psychoanalytic theory were all the
rage at the time, he found that much of what he read was speculative, with
little or no research backing (Goldfried, 2001). By contrast, he also received
a firm grounding in principles of learning and perception that were based
on empirical research evidencebut which, at the time, seemed to have lim-
ited application for clinical practice. It was at an early point in his clinical
graduate training that Goldfried experienced firsthand the gap between
clinical practice and research.
While still in graduate school he also had the good fortune to meet and
have dinner with Paul Meehl. This was an especially rare treat for Goldfried,
as he had read virtually everything Meehl had written and had enormous
respect for his insights on research, practice, and the philosophy of science.
At one point during the evening, however, someone asked Meehl about the
extent to which his clinical work was informed by research. Without any hes-
itation, he replied, “Not at all.” As a clinical psychology graduate student,
struggling to adopt the identity of a scientist–practitioner, Goldfriend found
Meehl’s response deeply disheartening and, as it turned out, impactful.
Reflecting on this event in later years, he stated, “I don’t think I ever fully
recovered” (M. R. Goldfried, personal communication, January 2007). It is
noteworthy that since his graduate school days—over 50 years ago—bridging
the gap between research and clinical practice has become a defining theme
that has shaped his many contributions to clinical psychology training,
research, and practice.
A high point in his graduate career involved the completion of an intern-
ship at the Veterans Administration hospital in Palo Alto, California, in the
late 1950s. It was truly a golden era, with Ullmann and Krasner laying the
groundwork for behavior therapy at one end of the Psychology Department
while, at the other end, Bateson, Haley, and Weakland developed systemic
interventions for families. The exposure to a diverse range of theoretical,
research, and therapy approaches during his internship placement may have
planted the seeds for his later interest in psychotherapy integration.
130 CASTONGUAY AND NORCROSS

After conducting research on projective techniques at the University of
Rochester (Goldfried, Stricker, & Weiner, 1971), Goldfried joined the Psy-
chology Department at the State University of New York at Stony Brook in
1964 (where he has remained since) and helped develop a clinical psychol-
ogy doctoral program that was rooted in learning and experimental psychol-
ogy. To this day, Goldfried’s psychotherapy practice keeps him honest as a
clinical researcher; his involvement in research keeps informing clinical prac-
tice; and his work with graduate students keeps him continually exploring
how each activity can inform the other.
MAJOR CONTRIBUTIONS
Goldfried’s scholarly efforts have all been directed toward creating a

deeper, more integrative understanding of therapeutic change as it manifests
itself in a diverse range of therapeutic approaches and clinical samples. In
doing so, he has developed or contributed to four key ideas, discussed in detail
in this section, that have led to better integration within the field of psycho-
therapy research and practice.
Cognitive–Behavior Therapy
After graduate training in the psychodynamic tradition (an approach,

which at the time, dominated the field), Goldfried became an early and
influential proponent of behavior therapy. He conducted an impressive
number of studies that helped to establish the psychometric quality and clin-
ical utility of behavioral assessment, as well as the effectiveness of behavioral
interventions. As such, Goldfried’s research helped behavior therapy gain
credibility in the eyes of both clinicians and researchers. His work played a
determinant role in establishing behavior therapy as a powerful approach that
could effectively address complex and severe psychopathology—as opposed
to an aggregation of mechanistic techniques dealing with relatively simple
problems experienced by nonclinical populations (e.g., college students). In
a very real sense, research conducted by Goldfried and his colleagues helped
behavior therapy move from the ivory tower of academia to the reality of
day-to-day clinical practice.
At the same time, Goldfried emerged as one of the pioneers of the cog-
nitive revolution in behavior therapy. He agreed with the criticism of behav-
ior therapy as exclusively focused on overt behavior and its reliance of
classical and operant learning models with limited clinical value. Goldfried
pursued several influential research studies demonstrating, among other crit-
ical constructs, the importance of self-control and cognitive coping skills in
MARVIN R. GOLDFRIED 131

therapeutic change. He was actively involved with a number of colleagues
(e.g., Beck, Davison, Ellis, Mahoney, Meichenbaum) in facilitating CBT within
the field through workshops and conferences. These efforts eventually led to
establishing the journal Cognitive Therapy and Research, for which he served as
associate editor. Over the years, his numerous methodological (e.g., Goldfried
& D’Zurilla, 1969), empirical (e.g., D’Zurilla & Goldfried, 1971), theoretical
(e.g., Goldfried & Robins, 1982), and clinical (e.g., Goldfried & Davison, 1976,
1994) publications have become classics in the cognitive–behavioral literature.
In particular, Goldfried launched a seminal research program on
cognitive–behavioral methods for coping with anxiety. He and his colleagues
conducted outcome studies on the reduction of social anxiety, test anxiety,
public speaking anxiety, and unassertiveness. The methods applied here were
based on the premise that, in addition to using relaxation as a coping skill,
individuals could reduce their anxiety by helping them more realistically
reevaluate their perception of threat. Designed to help clients develop self-
control or self-regulation, the coping skills training developed by Goldfried
and his colleagues went a long way to counter the accusation (voiced by many
humanistic and psychodynamic therapists in the 1960s and 1970s) that behav-
ioral interventions undermined the client’s autonomy and independence. As
Marsha Linehan (personal communication, January 2007) has eloquently
argued, Goldfried’s notion that the core mechanism of many CBT treatments
is the development of new behavior skills has led to the development of new
treatments and the enhancement of existing CBT interventions.
One of these methods, problem solving training, has received particu-
lar attention over the last 20 years, having been shown to be helpful for prob-
lems such as depression, suicidal behavior, substance abuse, family conflict,
childhood aggression, and mental retardation (Goldfried, Greenberg, &
Marmar, 1990). Studies conducted in both naturalistic and controlled set-
tings have shown that the resolution of specific problems is one of the helpful
events most frequently identified by clients (Llewelyn, 1988; Llewelyn et al.,
1988). Irrespective of their preferred theoretical orientation, therapists are
likely to increase their ability to respond to their clients’ needs by using strate-
gies that Goldfried and his colleagues have developed to systematically and
explicitly facilitate problem solving (i.e., problem definition, generation of
alternatives, decision making, action taking, verification). A detailed descrip-
tion of these interventions, together with other cognitive–behavioral methods,
appeared as Clinical Behavior Therapy, coauthored with Davison. Originally pub-
lished in 1976, the book has been classified as a Social Science Citation Classic,
was reissued in an expanded edition in 1994, and has sold over 35,000 copies.
Behavior therapy has successfully integrated cognition in recent decades,
but emotional arousal has only recently been considered. In the past, emo-
tion has typically been viewed as something that needs to be reduced, man-

aged, or contained. Wiser and Goldfried (1993), for example, found that
in treating depressed clients, cognitive–behavior therapists viewed lowering
emotional experiencing as significantly contributing to the process of thera-
peutic change. By contrast, psychodynamic and experiential therapists con-
sidered increasing emotional experiencing to be clinically significant.
Interestingly, Goldfried and his colleagues have found that the client’s
level of experiencing predicts outcome in cognitive therapy (Castonguay et al.,
1996). Clinically, these findings suggest that even though many CB thera-
pists may not have been trained to foster emotional deepening, they should
consider using methods that have been developed in other orientations to do
so. These therapists will find in recent contributions from Goldfried (e.g.,
Samoilov & Goldfried, 2000) guidelines to assimilate such methods into their
clinical repertoire, in what he has labeled cognitive–affective behavior therapy.
Psychotherapy Integration
While contributing to research and practice of CBT, Goldfried remained

constantly open to the merits of diverse forms of psychotherapy. The notion
of creating bridges among the different theoretical orientations dates back to
the early 1930s and has been raised over the years by such luminaries as Franz
Alexander, Thomas French, John Dollard, Neal Miller, and Jerome Frank.
However, it remained a latent theme until the 1980s, when Goldfried and col-
leagues began working in this area. Some 30 years later, not only has integra-
tion or eclecticism emerged as a definite research area but it has also become
the modal theoretical orientation among mental health professionals in North
America and Western Europe (Norcross & Goldfried, 2005).
Goldfried was a pioneer in the psychotherapy integration movement. He
has published some of the most influential work in this growing force in our field
(e.g., Goldfried, 1982; Norcross & Goldfried, 2005) and is internationally rec-
ognized, along with a few others, as a leader of the integration movement—
both organizationally and scientifically.
Recognizing that a network of professionals might facilitate a rapproche-
ment across theoretical orientations, Goldfried and Paul Wachtel cofounded
the Society for the Exploration of Psychotherapy Integration (SEPI) in 1983.
This visionary organization and its journal, Journal of Psychotherapy Integration,
has been a catalyst worldwide for the advancement of integrative approaches
to psychotherapy research and practice. For psychotherapists whose practices
are unencumbered by a single theory, SEPI has provided a forum to explore
points of convergence and complementarity among differing systems of psycho-
therapy. And for therapists who have been accused of illegitimacy, heresy,
or worse for their unwillingness to adopt a “purist” approach when con-
fronting the complexity of clinical reality, SEPI is an important reference

group that includes highly respected scholars who represent a wide range of
theoretical orientations and therapy approaches.
In addition to cofounding SEPI, Goldfried has championed the need for
empirical research studies evaluating the process and outcome of integrative
therapeutic approaches. Not only has he been instrumental in identifying the
agenda for researchers interested in integrative and eclectic therapy (see Wolfe
& Goldfried, 1988), but he also is among a select group of psychotherapy
researchers who have developed a productive research program in psycho-
therapy integration (Goldfried, 1991).
Psychotherapy Process
Across the decades and throughout his career, Goldfried has contributed
significantly to the study of the psychotherapy process. His work on psycho-
therapy integration, in particular, took the form of comparative process and
process–outcome research. Many practitioners are committed to going beyond
the boundaries of a single theoretical orientation, but until recently there was
little in the research literature to support doing so.
In a seminal 1980 article in American Psychologist, Goldfried persua-
sively argued that treatment methods prescribed by particular approaches
are largely (though not entirely) idiosyncratic manifestations of a smaller
number of change principles that cut across disparate psychotherapies. He
described such principles of change as heuristics or guidelines at a middle-
level of abstraction that exists somewhere between the specific treatment
methods (e.g., interpretation, cognitive restructuring, two-chair) and the
global theoretical systems (e.g., psychoanalytic, cognitive–behavioral, expe-
riential). The delineation and identification of key principles of change (e.g.,
establishment of productive relationship, provision of a new view of self) in
differing therapy approaches has offered the field a new integrative concep-
tualization of how client change happens in psychotherapy.
Although not the first to explicate common factors or to promote prin-
ciples of change, Goldfried spurred a renewed interest in these matters and
offered an explanation for a perplexing paradox in psychotherapy research,
specifically, that diverse forms of psychotherapy tend to produce equivalent
outcomes. The principles of change have guided Goldfried and his colleagues
in their investigating of unique and common mechanisms of change across
different forms of psychotherapy.
As part of their research program, they developed an instrument to mea-
sure the therapist’s focus in attempting to offer the patient a new view of self
(Goldfried, Newman, & Hayes, 1989). In one of the earliest studies, Goldfried
and colleagues found that cognitive–behavioral (CB) and psychodynamic–
interpersonal (PI) therapists placed a comparable focus on intrapersonal and

interpersonal content, but that the intrapersonal focus (e.g., link between
thoughts and emotions) was associated with improvement only in the CB
therapy, whereas the interpersonal emphasis (e.g., maladaptive patterns of
relating to self) was associated with change in only the PI condition (Kerr
et al., 1992). Whereas the therapist’s intrapersonal focus in CB predicted
symptom change, the therapist’s interpersonal focus in PI was associated with
improvement in self-esteem and social functioning. These and related studies
suggest that complementary mechanisms of change may be operating across
different treatments.
Of particular significance in Goldfried’s investigation of therapist’s focus
of interventions are the results of two studies that suggest that CBT and PI
are much more similar when applied in a naturalistic clinical setting than
when conducted as part of research clinical trials (Goldfried, Castonguay,
Hayes, Drozd, & Shapiro, 1997; Goldfried, Raue, & Castonguay, 1998).
These results added evidence to support a growing concern, shared by many
researchers and clinicians, that RCTs may not necessarily reflect the way
psychotherapy is conducted in actual clinical settings (Norcross, Beutler, &
Levant, 2005).
Goldfried and students have also investigated another principle of
change: the therapeutic alliance. A study conducted by Goldfried’s research
team was one of the first to demonstrate a positive relationship between the
working alliance and patient outcome in CBT (Castonguay et al, 1996). Clin-
ically speaking, psychotherapists—even those practicing within a tradition that
has been slow to recognize the curative effect of the therapeutic relationship—
should strive to establish and maintain a strong bond and active collaboration
with their clients.
Lesbian, Gay, and Bisexual Issues
Goldfried has extended the theme of integration by incorporating

LGB literature into mainstream psychology. He made a decision in 1999 to
“come out” professionally not as a gay man but as the father of a gay son and
then formed a network of family members within psychology who have gay,
lesbian, or bisexual relatives (Goldfried, 2001). Members of AFFIRM: Psy-
chologists Affirming Their Gay, Lesbian, and Bisexual Family are dedicated
to supporting their own family members as well as to encouraging research
in this area. Goldfried decided to establish AFFIRM after he attended a
parade in support of gay rights, with his wife, and was told by many partic-
ipants how much they regretted not receiving similar support from their
parents and family. AFFIRM now counts more than 700 family members,
including a large number of distinguished psychologists, two of whom are past
presidents of the American Psychological Association. This organizational

tour de force, born out of deep nurturing and sensitivity to painful experi-
ences, conveys not only Goldfried’s affiliative nature but also his vision and
pioneering spirit.
His influential articles in American Psychologist, Psychotherapy, and Clin-
ical Psychology: Science and Practice brought to the fore neglected research and
practice questions on LGB issues. Insightfully, Goldfried has shown that
while many of these matters remain “invisible” to psychotherapists, they have
important implications for their practice. For example, his work urges clini-
cians to address the high prevalence of teenage suicideand substance abuse,
as well as victimization and abuse, among LGB clients when constructing case
formulations and making treatment recommendations.
His research team continues to carry out a number of studies on LGB
issues, which are likely to improve our understanding of human functioning
and the change process. These include investigations of bias in diagnosing
LGB adolescents who are in the process of accepting their sexual orientation,
what LGB individuals are looking for in a potential therapist, attitudes toward
gender-atypical lesbians, and how the prevalence of social anxiety among gay
men may vary with their acceptance of their sexual orientation.
OTHER ACCOMPLISHMENTS
In the mid-1990s, Goldfried created a unique journal aimed at bridging

the divide between research and practice as well as the gap across different
therapeutic orientations. The journal, In Session: Psychotherapy in Practice,
was designed to feature clinical guidelines, case illustrations, and summaries
of research findings for practicing therapists—not other researchers. Because
the contributions reflected different orientations, all articles were written in
theory-neutral, jargon-free English. In 2000, the quarterly journal became a
branch of the Journal of Clinical Psychology, enabling wider circulation and
greater practitioner impact. The Journal of Clinical Psychology: In Session now
reaches more than 2,500 libraries around the world and literally tens of thou-
sands of mental health professionals and those in training.
In addition to his editorial contributions, Goldfried has served on the
National Institute of Mental Health (NIMH) study section dealing with
psychosocial interventions and has participated in several NIMH workshops
aimed at establishing guidelines for future research on issues such as process
research, psychotherapy integration, and treatment development. As an
organization leader, beyond SEPI, he served as the president of the Society
for Psychotherapy Research, chaired the Research Committee of the APA
Division of Psychotherapy, where he also was also a member of its Presiden-
tial Task Force on Empirically Supported Therapy Relationships.

In addition to these accomplishments, Goldfried has instilled an inter-
est in and taught the skills of psychotherapy research to several generations
of researchers. His mentoring began with the Stony Brook postdoctoral pro-
gram in behavior therapy, and it has continued since the 1960s in his teach-
ing and supervision of several generations of postdoctoral and graduate
students in clinical psychology, many of whom have gone on to influential
positions of their own. On a short list are Louis G. Castonguay, Adele M.
Hayes, Cory F. Newman, Clive J. Robins, and Marsha Linehan. The mentor-
ing did not stop with their postdoctoral or graduate education and has typi-
cally continued throughout their careers. He has also mentored junior faculty
members at Stony Brook, as well as colleagues at other institutions (e.g., John
Norcross, Jeremy Safran).
CONCLUSION
Marvin R. Goldfried has been a relentless pioneer in psychotherapy

research and practice—charting new areas, pushing the frontiers, and
expanding the terrain. In each of his seminal contributions, he has been an
integrating force—bringing disparate, even conflicting, forces together and
narrowing the practice–research gap. In many ways, his work has altered how
researchers conceptualize, conduct, and investigate psychotherapy. He has
raised awareness about the importance of cognition and emotion (especially
in the minds of social-learning therapists). By delineating principles of
change that cut across different orientations, he has brought clarity to basic,
transtheoretical components of therapy and catalyzed the psychotherapy
integration movement. He has increased therapists’ clinical repertoire by
developing behavioral methods of assessment and treatment, as well as by
incorporating experiential methods into CBT. His process research has influ-
enced many researchers to attend to the mechanisms of change in addition
to treatment outcome. He has challenged the profession to recognize social
and political biases, as reflected in his work on GLB issues. By all accounts,
Dr. Goldfried’s seminal contributions have been partly responsible for several
of the most exciting and beneficial advancements in psychotherapy.
REFERENCES
Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. H. (1996).
Predicting outcome in cognitive therapy for depression: A comparison of unique
and common factors. Journal of Consulting and Clinical Psychology, 64, 497–504.
doi:10.1037/0022-006X.64.3.497

D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modifica-
tion. Journal of Abnormal Psychology, 78, 107–126. doi:10.1037/h0031360
Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles.
Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends in psycho-
dynamic, humanistic, and behavioral practice. New York, NY: Springer.
Goldfried, M. R. (1991). Research issues in psychotherapy integration. Journal of
Psychotherapy Integration, 1, 5–25.
Goldfried, M. R. (2001). Integrating gay, lesbian, and bisexual issues into mainstream
psychology. American Psychologist, 56, 977–988. doi:10.1037/0003-066X.56.11.977
Goldfried, M. R., Castonguay, L. G., Hayes, A. H., Drozd, J. F., & Shapiro, D. A.
(1997). A comparative analysis of the therapeutic focus in cognitive-behavioral
and psychodynamic-interpersonal sessions. Journal of Consulting and Clinical
Psychology, 65, 740–748. doi:10.1037/0022-006X.65.5.740
Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York, NY:
Holt, Rinehart & Winston.
Goldfried, M. R., & Davison, G. C. (1994). Clinical behavior therapy (Expanded ed.).
New York, NY: Wiley-Interscience.
Goldfried, M. R., & D’Zurilla, T. J. (1969). A behavioral-analytic model for assess-
ing competence. In C. D. Spielberger (Ed.), Current topics in clinical and commu-
nity psychology (Vol. 1, pp. 151–196). New York, NY: Academic Press.
Goldfried, M. R., Greenberg, L. S., & Marmar, C. (1990). Individual psychotherapy:
Process and outcome. Annual Review of Psychology, 41, 659–688. doi:10.1146/
annurev.ps.41.020190.003303
Goldfried, M. R., Newman, C., & Hayes, A. M. (1989). The coding system of therapist
focus. Unpublished manuscript, State University of New York at Stony Brook.
Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in
significant sessions of master therapists: A comparison of cognitive-behavioral
and psychodynamic-interpersonal interventions. Journal of Consulting and
Goldfried, M. R., & Robins, C. (1982). On the facilitation of self-efficacy. Cognitive
Therapy and Research, 6, 361–379. doi:10.1007/BF01184004
Goldfried, M. R., Stricker, G., & Weiner, I. B. (1971). Rorschach handbook of clinical
and research applications. Englewood Cliffs, NJ: Prentice-Hall.
Kerr, S., Goldfried, M. R., Hayes, A. H., Castonguay, L. G., & Goldsamt, L. A.
(1992). Interpersonal and intrapersonal focus in cognitive-behavioral and
psychodynamic-interpersonal therapies: A preliminary analysis of the Sheffield
Project. Psychotherapy Research, 2, 266–276.
Llewelyn, S. P. (1988). Psychological therapy as viewed by clients and therapists.
British Journal of Clinical Psychology, 27, 223–237.

Llewelyn, S. P., Elliott, R., Shapiro, D. A., Hardy, G., & Firth-Cozens, J. (1988).
Client perceptions of significant events in prescriptive and exploratory periods
of individual therapy. The British Journal of Clinical Psychology, 27, 105–114.
Norcross, J. C., Beutler, L. E., & Levant, R. F. (2005). (Eds.). Evidence-based practices
in mental health: Debate and dialogue on the fundamental questions. Washington,
DC: American Psychological Association.
Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integra-
tion (2nd ed.). New York, NY: Oxford University Press.
Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior ther-
apy. Clinical Psychology: Science and Practice, 7, 373–385. doi:10.1093/clipsy/7.4.373
Wiser, S. L., & Goldfried, M. R. (1993). A comparative study of emotional expe-
riencing in psychodynamic-interpersonal and cognitive-behavioral thera-
pies. Journal of Consulting and Clinical Psychology, 61, 892–895. doi:10.1037/
0022-006X.61.5.892
Wolfe, B. E., & Goldfried, M. R. (1988). Research on psychotherapy integration:
Recommendations and conclusions from an NIMH workshop. Journal of Con-
sulting and Clinical Psychology, 56, 448–451. doi:10.1037/0022-006X.56.3.448

12
MICHAEL J. LAMBERT: BUILDING
CONFIDENCE IN PSYCHOTHERAPY
BENJAMIN M. OGLES AND JEFFREY A. HAYES
Michael J. Lambert has been a leading voice for psychotherapy research

and a key figure in bridging the gap between clinical research and practice for
4 decades. His early work began with his conducting comprehensive reviews
and meta-analyses that made coherent arguments for the effectiveness of
psychotherapy in the midst of a fierce debate regarding the potential influ-
ence of spontaneous remission on client improvement (Lambert, 1976).
Since that early work, he has published numerous books, chapters, reviews,
and primary studies that have made additional important contributions to
clinical practice through addressing such questions as: Do measures of ther-
apy outcome influence the perceived effect of psychotherapy? How much
therapy is necessary to produce meaningful change? Is graduate training nec-
essary to conduct effective psychotherapy? What are the essential ingredients
of effective therapy? Do clients get worse during psychotherapy, and if so,
what factors contribute to deterioration and how can deterioration be pre-
vented? How can research methods be used in practice to inform the clini-
cian regarding client progress during treatment? This chapter provides a brief
overview of Dr. Lambert—not only his work, but also his personal back-
ground and characteristics and connections between the two.
141
MAJOR CONTRIBUTIONS
To a large degree, the focus of Michael J. Lambert’s research has been

a response to the most pressing questions facing the field during the course
of his long and distinguished career. At the outset of his work, for example,
Lambert’s scholarship addressed questions regarding the helpfulness of client-
centered variables and whether psychotherapy was more effective than either
time alone or placebo conditions (e.g., Lambert, 1976). His research in these
areas has advanced professional understanding about therapist interpersonal
skills, spontaneous remission, and placebo effects. Throughout his career,
Lambert also has been interested in whether psychotherapy might have harm-
ful effects, and if so, what the contributing factors to patient deterioration
were (Lambert, Bergin, & Collins, 1977). In addition, Lambert’s work has
contributed greatly to the field’s knowledge about dose–response relation-
ships, as well as the measurement of psychotherapy outcome (e.g., Lambert,
1992; Lambert, Christensen, & DeJulio, 1983). For example, Lambert con-
ducted research and wrote literature reviews that deepened the field’s under-
standing of clinically significant change and that helped establish cutoff scores
for popular instruments such as the Beck Depression Inventory (Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961), Symptom Checklist-90 (Derogatis,
1994), Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer et al.,
1988), and Hamilton Depression Rating Scale (Hamilton, 1967).
Lambert later developed the Outcome Questionnaire-45 (OQ-45;
Lambert, Hansen, Umphress, et al., 1996), which has become a widely used
measure of client distress in both clinical and research contexts (with trans-
lations into more than 15 languages). Lambert’s own program of research with
the OQ-45 used statistical modeling to predict patient treatment response,
including treatment failure. With an ever-present eye toward integrating
research and practice, Lambert developed and tested software that could
quickly deliver information to therapists, demonstrably improving patient
outcomes, especially in cases in which patients were progressing poorly or
were in danger of deteriorating. This research led to the identification of com-
mon factors, such as the working alliance and patient motivation, to which
therapists need to attend when patients are not progressing well in psycho-
therapy. Research on these interventions is being undertaken in settings
across the globe, including China, Australia, the Middle East, and Europe, all
places where the interventions are also being routinely used.
One of Lambert’s most influential scholarly contributions to psycho-
therapy research involved his work on the multiple editions of the Handbook
of Psychotherapy and Behavior Change. His early chapters, written with Allen
Bergin, provided comprehensive overviews on the effects of psychotherapy
142 OGLES AND HAYES

and shaped the direction of many scholars’ research programs. Of equal impor-
tance, these chapters were written in a clinically relevant manner so that
research findings could be applied to the practice, supervision, and training of
psychotherapy. Lambert eventually assumed an editorial role with the fifth edi-
tion of Handbook of Psychotherapy and Behavior Change, and his dual emphasis
on scholarly excellence and clinical relevance continued to be apparent in
his work as editor (Lambert, 2004).
EARLY BEGINNINGS
Mike Lambert was one of five children born and raised in Salt Lake City,
Utah. His father was a small business owner who finished his career operat-
ing a successful travel agency. His mother stayed at home to raise the children.
Lambert was part of a large and engaged extended family that worked, played,
worshipped, and traveled together. He was an energetic youth who enjoyed
outdoor activities. As a teenager, he was an avid sportsman who excelled in
wrestling—he was the state champion in his weight class as a junior in high
school. Later in life, he took up tennis and biking, but he also enjoyed
basketball and other sports. When a young faculty member, he occasionally
ended up in a wrestling match with a student or two when traveling to
research conferences. Although the students were often bigger, Lambert was
a formidable challenge who could never be pinned. Lambert has shared fond
memories of his childhood with his students and displayed the interpersonal
ease that is often typical of a child raised in a large family.
Lambert married his high school sweetheart soon after he graduated
from high school. His responsibilities were increased when they had their first
child before Lambert was 19 years old. As a result, he moved quickly into
adulthood with family responsibilities while also working to gain an under-
graduate and then graduate degrees. These were financially challenging years
for the Lamberts, filled with many hours of work, class, study, and caring for
family. By the time Lambert graduated with his PhD in counseling psychol-
ogy from the University of Utah in 1971, he and his wife, Linda, had four chil-
dren of their eventual five.
Lambert was first introduced to the field when he enrolled in a high
school psychology class. While still in high school, he also stumbled on and
read Karl Menninger’s The Human Mind (1945). Its numerous case studies
and in-depth analyses fascinated him, and he began to consider the possibil-
ity of becoming a practicing psychologist. He later enrolled in an educational
psychology course taught by Ted Packard, at the same time he was working
as an undergraduate research assistant for Ernst Beier. Both of these faculty
MICHAEL J. LAMBERT 143

members encouraged Lambert to consider applying for the doctoral program
at the University of Utah.
During his graduate years, Lambert was drawn to the work of Carl
Rogers, whose humanistic theory became the foundation of Lambert’s research
and practice throughout his career. He completed his internship at the Uni-
versity of Utah counseling center in a half-time appointment over 2 years.
During that time, he also completed his dissertation, which involved the
recording and analysis of parallel processes of therapy and supervision tapes.
Thus, Lambert began his foray into therapy research.
After graduating from the University of Utah, Lambert accepted a job
with joint appointments as a psychologist in the health center and faculty
member in the psychology department at Brigham Young University. There,
he became acquainted with Allen Bergin and began a successful collaboration
that spanned decades. Lambert later moved into a full-time faculty position.
His early work focused on documenting whether therapy was effective through
critical reviews of the primary research literature. Several early themes evolved
in his writing including methods used to evaluate treatment efficacy and espe-
cially the instruments used to assess outcome, the contribution of the thera-
pist to treatment success, the degree to which specific versus common factors
could account for treatment success, deterioration in treatment, and the
increased variability in outcomes for treated versus control subjects, and the
role of supervision in training. These early themes dominated his writing for
more than 30 years.
ACCOMPLISHMENTS
Lambert has been an important contributor to psychology as a profes-

sion, the study of psychotherapy, and the practice of psychotherapy. It will
not be possible to catalog all of his writing, mentoring, or service in this chap-
ter, yet we review some of his most prominent and important accomplish-
ments to date.
Research Studies
As mentioned earlier, Lambert’s work reflected the profession’s evolv-

ing theoretical and scientific questions of the day and increasingly addressed
contemporary societal and practical issues. In the early 1970s, for example,
the profession was concerned with issues related to spontaneous remission,
Rogerian therapist-offered conditions, and the effects of psychotherapy. In
response to these concerns, Lambert wrote critical and synthetic reviews of
the literature in each of these areas that appeared in prestigious and influen-
144 OGLES AND HAYES

tial outlets such as Psychological Bulletin and the Journal of Consulting and Clin-
ical Psychology. Lambert’s work helped establish that psychotherapy is supe-
rior to no treatment and placebo treatment conditions, that the positive
effects of therapy are achieved fairly quickly and are relatively enduring, and
that, whereas most patients do benefit from therapy, some patients deterio-
rate during the course of—and perhaps because of—sychotherapy. These
same issues were important to Allen Bergin as well, as reflected in the atten-
tion he devoted to them in the first edition of the Handbook of Psychotherapy
and Behavior Change. Lambert and Bergin both joined the faculty at Brigham
Young University in 1971, the year the first edition of the Handbook was pub-
lished, and their relationship had a considerable effect on Lambert’s scholarly
work, most notably in his long-standing association with the Handbook.
Lambert conducted meta-analyses and wrote integrative reviews on
other highly pertinent topics as well, such as the effectiveness of time-limited
dynamic therapy, the use of various instruments for measuring psychotherapy
outcome, and the effectiveness of supervision. In addition, Lambert con-
ducted meta-analyses that indicated that, whereas therapist training may help
decrease patient dropout rates, on the whole, therapist experience demon-
strates only a slight relationship with outcome. Not only did his scholarship
continually address contemporary professional issues, he actually anticipated
and helped the field begin to focus on significant concerns such as the use of
therapy manuals (Lambert & Ogles, 1988) and the importance of individual
therapist variables as opposed to techniques (Lambert, 1989).
When Lambert “left” graduate school in 1971 (his own typically mod-
est words, which might erroneously suggest that he dropped out), his profes-
sional goals were to positively influence the practice of psychotherapy and
to help clients feel and function better—both his own clients and, through
his research, others’ clients. Consequently, throughout his career, Lambert
sought to make his research clinically relevant. His program of research was
dedicated to enhancing patient outcome by providing feedback to therapists
on patient progress. As mentioned previously, this line of research began
with intensive and rigorous development of the OQ-45. The OQ-45 is a
45-item measure of outcome developed specifically to be brief enough, while
maintaining sound psychometric properties, to administer repeatedly during
treatment. The instrument has three subscales—symptom distress, inter-
personal functioning, and social role performance—but the total score is
most frequently used in both research and practice. Scores range from 0 to
225. The questionnaire correlates significantly with other outcome measures
of symptomatic distress, such as the SCL-90-R and Beck Depression Inven-
tory and has been extensively tested for reliability, validity, and sensitivity to
change (e.g., Lambert et al., 1996; Vermeersch, Lambert, & Burlingame,
2000). Once the OQ-45 was developed, Lambert conducted a series of

naturalistic studies that predicted outcome based on the patient’s initial
disturbance and early rate of progress and were used to provide feedback to
therapists. This research established that providing feedback to therapists
about patient progress reduced patient deterioration, increased clinically
significant client change rates, and enhanced the cost-effectiveness of
therapy (Lambert, 2007).
In one of the studies in this program of research, Lambert and his col-
leagues analyzed naturalistic data from more than 10,000 patients who received
psychotherapy from a broad range of therapists in a wide variety of settings
(e.g., university counseling centers, employee assistance programs, commu-
nity mental health centers, managed care settings; Lambert, Hansen, &
Finch, 2001). In this highly cited study, survival analyses determined that half
of patients who were categorized as dysfunctional at the outset of treatment
could be expected to achieve clinically significant change after 21 sessions of
psychotherapy. That is, about 21 sessions are necessary for 50% of clients to
meet two criteria that have been defined by Jacobson and Truax (1991) as
clinically significant change. First, they make large enough changes that the pre-
to posttreatment difference score could be considered a reliable change (reli-
able improvement) and, second, their posttreatment scores fall in the range
of individuals in the general population (recovery). Using the less rigorous
standard of reliable improvement (without recovery), half of dysfunctional
patients could be expected to improve after seven sessions and 75% after 14 ses-
sions. In addition, the data were used to develop growth curves based on patient
initial disturbance and the degree to which patients varied from expected
improvement at particular treatment sessions. This information was then
used to alert therapists that a patient was a potential treatment failure so that
corrective steps could be taken. Lambert’s subsequent research suggested that
these corrective steps might include assessing the client’s social support and
motivation, as well as the strength of the working alliance, to redirect the
course of therapy. These three variables, collectively, were referred to as clin-
ical support tools that could provide beneficial information to the therapist
whose client was at risk of deterioration.
In a particularly impressive study investigating the effects of providing
feedback to therapists, Lambert and his colleagues (Harmon et al., 2007)
examined outcome data from 1,374 university counseling center clients who
were randomly assigned to one of two treatment conditions. In the first con-
dition, both the client and therapist received feedback about the client’s
progress, and in the second condition, only the therapist received feedback.
In each of these two conditions, clients whose clinical progress suggested that
they were at risk of deterioration were further randomly assigned to condi-
tions in which their therapists did or did not receive feedback on clients’ per-
146 OGLES AND HAYES

ceptions of the alliance, social support, and readiness for change (the clinical
support tools). Outcome data on these 1,374 clients were compared with
archival data from 1,445 university counseling center clients whose therapists
did not receive any feedback on client progress. Results indicated that client
outcome is enhanced by providing therapists with information on client
progress, although outcome is not affected by also giving clients feedback on
their progress. Furthermore, among clients whose early OQ-45 scores and tra-
jectories indicated that they were in danger of deteriorating, 42% demon-
strated reliable improvement when therapists received feedback that included
data from both the OQ-45 and the clinical support tools. Only half as many
clients demonstrated reliable improvement when therapists received no feed-
back. In fact, on average, at-risk clients showed essentially no improvement
when therapists were not provided any feedback about their clients, whereas
clients improved 14 points on the OQ-45 when therapists received feedback
on client progress and clinical support tools.
In response to larger societal issues, later in his career, Lambert’s meta-
analytic and other scholarly work addressed broad concerns such as the extent
to which psychotherapy reduces health care costs, quality management in
diverse settings, accountability through outcome measurement, and the use
of clinical significance markers to improve patient care (Chiles, Lambert, &
Hatch, 1999). Lambert’s scholarship in these areas carried policy implica-
tions in terms of managed care practices, and he engaged in consulting work
to help translate his research findings into practice settings serving thou-
sands of individuals.
OTHER CONTRIBUTIONS
In addition to a prolific research career, Lambert has also contributed to

the field of psychotherapy research through his editorial work. He reviewed
hundreds of journal articles as an ad hoc journal editor and served as the asso-
ciate editor of the Journal of Consulting and Clinical Psychology for a 5-year
term. He also served as the editor of several books, including the fifth edition
of the Handbook of Psychotherapy and Behavior Change. He also served as the
president of the Society for Psychotherapy Research and received the Distin-
guished Career Award from the same organization for lifelong contributions
to psychotherapy research.
Lambert served on the State Licensing Board for the State of Utah and
provided service through a small private practice for more than 30 years. As
a faculty member, he also served as the director for many important disserta-
tions that contributed to the psychotherapy literature. Clearly, Lambert’s pro-
fessional contributions extend far beyond his published studies.

INFLUENCES
Lambert made a clear distinction between those individuals who influ-

enced his thinking about and research concerning psychotherapy and those
who influenced his clinical practice. Although much of his research has had
a direct influence on his own and others’ practice, the individuals who played
a foundational role in his thinking about practice tended to be a different
group from those who influenced his writing and research.
As a clinician, Lambert was trained as a counseling psychologist in a
department that was heavily steeped in Rogerian humanism. Although he
met Carl Rogers only a couple of times for brief interactions, Lambert was pro-
foundly influenced by Rogers’s writing and thinking about the necessary con-
ditions for successful therapy. This academic exposure was supplemented and
eclectically expanded by the supervision he received in graduate school from
Ted Packard, Addie Furhiman, Bob Finley, and Ernst Beier. He was also influ-
enced by the interpersonal theories expressed in the writing of Harry Stack
Sullivan.
This foundational Rogerian tradition matched well with Lambert’s per-
sonal style. As a clinician, supervisor, researcher, and mentor, he displays an
uncommon openness to ideas. He is genuinely curious about how each per-
son views the world and almost eager to learn of the unique way in which
each person interprets and negotiates interpersonal situations. This nonjudg-
mental attitude pervades his interactions and results in unusual and rare con-
versations with students and colleagues. For example, one of this chapter’s
authors has observed Mike Lambert listening intently to an inexperienced
undergraduate’s ideas about therapy research as though the student were a
senior colleague who had just discovered the key to successful therapy. This
same ability to engage in a genuine, open dialogue without judging forms the
foundation of his therapeutic relationships.
Within the research domain, Lambert worked closely with Allen Bergin
for many years. He was also drawn to the writing of Hans Strupp and Sol
Garfield, in part because of their association with the writing of the Handbook
of Psychotherapy and Behavior Change. He found the work of Jerome Frank to
be especially persuasive. Indeed, threads of Frank’s work can be clearly seen
in Lambert’s writing about the common factors contributing to therapeutic
effectiveness across therapy orientations. Lambert’s most recent and more
practice-oriented work was influenced by simultaneously occurring research
that was being conducted by Ken Howard. Indeed, Ken Howard, David
Orlinsky, Allen Bergin, and others in the original group of psychotherapy
researchers involved in the early years of the Society for Psychotherapy
Research also contributed to Lambert’s thinking through the open debate and
lively discussion that typified the annual meetings.
148 OGLES AND HAYES

CONCLUSIONS
When considering the broad range of Michael Lambert’s productive

research career, what might one conclude about his work in terms of its con-
tribution to and influence on clinical research and practice? We have selected
six central points that summarize the major contributions.
1. His early reviews and broad summaries of the therapy inter-
vention literature helped to consolidate and confirm the field’s
confidence in the scientific finding that, on average, psycho-
therapy is effective.
2. In an era when most therapy researchers were interested in vali-
dating their intervention (the independent variable), Lambert
highlighted the important contribution of the many measures of
change (the dependent variables). These outcome measures play
an important role in the determination of both the statistical and
clinical significance of therapy effectiveness. Outcome measures
also deserve to be studied in their own right as the science of ther-
apeutic intervention evolves. Finally, Lambert developed a mea-
sure (OQ-45) and important methods for effectively integrating
outcome measures into practice to evaluate ongoing change.
3. Some psychotherapy patients deteriorate. Lambert’s early work
attempted to highlight this fact, to get a sense for how preva-
lent such declines were, and he began to propose potential pre-
dictors of deterioration (including the possible negative effects
of therapy). His later work focused on developing and validat-
ing early warning systems for therapists through tracking ther-
apy progress in order to help intervene with clients and prevent
ultimate deterioration.
4. Lambert’s reviews of the therapy literature persuaded him that
common and relationship factors played the most significant
role in producing therapeutic change during psychotherapy,
especially as compared to technical variables. He remained an
important voice in the ongoing debate regarding the key ingre-
dients of change throughout his career.
5. Perhaps Lambert’s most significant practical or applied contri-
bution to psychotherapy was the development of feedback sys-
tems using the OQ-45 to alert therapists regarding ongoing
client progress. Embedded in this naturalistic research was the
concurrent reinforcement of the fact that client outcome may be
more related to the person of the therapist than to his or her theo-
retical orientation or specific interventions and techniques.

6. Beginning with his dissertation, Lambert had an interest in
the effects of supervision. In contrast to the typical study that
investigates the influence of supervision on the supervisee, he
maintained an interest in the potential influence of super-
vision on the supervisee’s client (Lambert & Ogles, 1997). As
a result, the early warning systems developed to inform the ther-
apist of potential deterioration are also available for informing
supervision.
As can be readily seen, Michael J. Lambert has had and continues to
have a broad and important influence on the practice of psychotherapy. In
addition, he leads scientific advances in both primary research and syntheses
of the literature with his prolific and insightful research. Perhaps most impor-
tant, he is helping to bridge the gap that is so often seen between research
and practice through the development of scientifically rigorous methods for
informing practice.
REFERENCES
Chiles, J. A., Lambert, M. J., & Hatch, A. L. (1999). The impact of psychological
interventions on medical cost offset: A meta-analytic review. Clinical Psychol-
ogy: Science and Practice, 6, 204–220. doi:10.1093/clipsy/6.2.204
Derogatis, L. R. (1994). SCL-90-R: Administration, scoring, and procedures manual.
Minneapolis, MN: National Computer Systems.
Hamilton, M. (1967). Development of a rating scale for primary depressive illness.
British Journal of Social and Clinical Psychology, 6, 278-296.
Harmon, S. C., Lambert, M. J., Smart, D. M., Hawkins, E., Nielsen, S. L., Slade, K.,
& Lutz, W. (2007). Enhancing outcome for potential treatment failures: Ther-
apist-client feedback and clinical support tools. Psychotherapy Research, 17,
379–392. doi:10.1080/10503300600702331
Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., & Villesenor, V. S. (1988).
Inventory of Interpersonal Problems: Psychometric properties and clinical appli-
cations. Journal of Consulting and Clinical Psychology, 56, 885–892.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to
defining meaningful change in psychotherapy research. Journal of Consulting and
Lambert, M. J. (1976). Spontaneous remission in adult neurotic disorders: A revision
and summary. Psychological Bulletin, 83, 107–119. doi:10.1037/0033-2909.83.
1.107
Lambert, M. J. (1989). The individual therapist’s contribution to psychotherapy
process and outcome. Clinical Psychology Review, 9, 469–485. doi:10.1016/0272-
7358(89)90004-4
150 OGLES AND HAYES

Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative
and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of
psychotherapy integration (pp. 94–129). New York, NY: Basic Books.
Lambert, M. J. (Ed.). (2004). Bergin & Garfield’s handbook of psychotherapy and behav-
ior change (5th ed.). New York, NY: Wiley.
Lambert, M. J. (2007). Presidential address: A program of research aimed at improv-
ing psychotherapy outcome in routine care: What we have learned from a decade
of research. Psychotherapy Research, 17, 1–14. doi:10.1080/10503300601032506
Lambert, M. J., Bergin, A. E., & Collins, J. L. (1977). Therapist induced deterio-
ration in psychotherapy patients. In A. S. Gurman & A. M. Razin (Eds.),
Effective psychotherapy: A handbook of research (pp. 452–481). New York, NY:
Pergamon Press.
Lambert, M. J., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D. A.,
Clouse, G. C., & Yanchar, S. C. (1996). The reliability and validity of the
Outcome Questionnaire. Clinical Psychology & Psychotherapy, 3, 249–258.
doi:10.1002/(SICI)1099-0879(199612)3:4<249::AID-CPP106>3.0.CO;2-S
Lambert, M. J., Christensen, E. R., & DeJulio, S. S. (Eds.). (1983). The assessment of
psychotherapy outcome. New York, NY: Wiley-Interscience.
Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research:
Using patient outcome to enhance treatment effects. Journal of Consulting and
Lambert, M. J., Hansen, N.B., Umphress, V., Lunnen, K., Okiishi, J.,
Burlingame, G., . . . Reisinger, C.W. (1996). Administration and Scoring Man-
ual for the Outcome Questionnaire (OQ 45.2). Wilmington, DE: American Pro-
fessional Credentialing Services.
Lambert, M. J., & Ogles, B. M. (1988). Treatment manuals: Problems and promise.
Journal of Integrative and Eclectic Psychotherapy, 7, 187–204.
Lambert, M. J., & Ogles, B. M. (1997). The effectiveness of psychotherapy supervision.
In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 421–446).
Menninger, K. A. (1945). The human mind (3rd ed.). New York, NY: Knopf.
Vermeersch, D. A., Lambert, M. J., & Burlingame, G. M. (2000). Outcome Ques-
tionnaire: Item sensitivity to change. Journal of Personality Assessment, 74,
242–261. doi:10.1207/S15327752JPA7402_6

13
CLARA E. HILL: A REBEL WITH
SEVERAL CAUSES
SARAH KNOX
Rare is the individual who has not only contributed to her or his profes-
sion’s accumulated knowledge but has also created new research methods
through which that very knowledge is gained. Perhaps rarer still is the researcher
who has selflessly shared her accumulated wisdom with colleagues and stu-
dents and, in so doing, has both enriched the experiences of all in her profes-
sion and planted the seeds for its continued growth. Clara E. Hill is that rare
individual. This chapter, after briefly summarizing her major contributions
and describing her early beginnings, will then more closely examine her
accomplishments in a variety of areas.
MAJOR CONTRIBUTIONS
Clara Hill’s contributions to her profession have indeed been profound.

Her work on therapeutic processes not only transformed how therapy process
research is performed but also added significantly to our understanding of the
experiences, both overt and covert, of therapists and clients during the ther-
apy endeavor. Building on her ever-increasing understanding of such therapy
processes, as well as her experiences training therapists, Hill also developed
153
an empirically and theoretically grounded, integrated approach to teaching
helping skills, one that is clearly articulated and accessible to helpers of all
developmental stages, and one that has become a central resource in many
training programs. In addition, she applied the same level of theoretical and
empirical thoroughness to her work with dreams and here, too, developed an
extremely useful model for working with clients’ dreams in therapy, a model
that has shaped research in this area. An additional, and no less remarkable,
contribution was her development of an intensely rigorous qualitative
method that has enabled researchers to examine new questions, in new ways,
and thereby further our understanding of therapy phenomena. Finally, she has
contributed powerfully to her profession through several leadership positions.
In each of these areas, Clara Hill’s passion and enthusiasm for psychotherapy,
whether in learning more about how psychotherapy works or in helping to
train psychotherapists, have been extraordinary.
EARLY BEGINNINGS
Clara Edith Hill was born on September 13, 1948, in Shivers, Mississippi,
the fourth of her parents’ five children (a younger sister died in infancy). Her
father, trained as a Baptist minister, had moved his family to Mississippi to be
a preacher in a small church. When he could not make enough money to sup-
port his family, he tried being a teacher; the income afforded by that profes-
sion was also insufficient, so he moved the family to Rockford, Illinois, where
he worked in a factory and Clara’s mother became a social worker. Given her
father’s training, religion was a constant presence in Clara’s early life, with
nightly Bible meetings and church all day Saturday and Sunday, as well as
Wednesday evenings. The Hills were also avid readers, through which Clara
learned to think for herself and discover a world beyond the religiously con-
fining environment of her home. Clara also played the flute from fifth grade
through her first year in college, and it was from band that she learned her
work ethic—“results, not excuses.” An eagerness to examine fundamental
questions and not necessarily conform to established dicta found its roots
early in Clara Hill’s life, and also carried through to her professional career.
As an adolescent, for example, Clara questioned her father regarding
Christian tenets, remaining unsatisfied with his response. “You just have to
believe.” Since that time, she has remained skeptical of and resistant to any
force (whether religious, psychotherapeutic, or political) that tries to use per-
suasion or coercion to convert others or impose its views.
Hill’s first year as an undergraduate at Southern Illinois University
(SIU) was difficult—both her religious upbringing and her uncertainty
regarding what she wanted to study left her on the outside. Once she decided
154 SARAH KNOX

to major in psychology, began working in a vision lab in the psychology
department, and made friends, she finally began to thrive. During one college
summer, Hill worked as a recreational assistant at a state hospital for adoles-
cents in Chicago. It was here that she realized that she wanted to work with
relatively healthy people (rather than with institutionalized patients)—
an early step on her eventual path to counseling psychology. As an undergrad,
Hill also took a class and did her honor’s thesis (later published) with Dr. John
Snyder, a counseling psychologist who supported her application to graduate
school and eventually became her doctoral advisor.
Hill started her doctoral program in 1970 and loved those years, for she
felt passionate about psychology and enjoyed her cohort of fellow students
(and married one of them, Jim Gormally). She found the counseling psychol-
ogy faculty at SIU open and supportive; they believed their students had
worthwhile things to say and allowed them to freely pursue their own inter-
ests. The training she received in helping skills (based on Carkhuff, 1969) was
invaluable both professionally and personally, and she experienced several early
successes, with her research appearing in top-tier journals. From her graduate
school years alone, in fact, Hill had 11 refereed publications. Her strongest
influences in graduate school (primarily of humanistic and behavioral orienta-
tions) were John Snyder, Bill Anthony, Vince Harren, Jim O’Donnell, Dave
Rimm, and Paul Schauble.
Clara Hill finished her doctorate in 4 years (including a year-long intern-
ship at the University of Florida) and initially planned to seek a clinical posi-
tion. After a conversation with John Snyder, however, she decided to pursue
an academic track, for doing so would provide her more professional options.
She took a position as an assistant professor in the counseling psychology pro-
gram in the Department of Psychology at the University of Maryland, and she
has remained there ever since. Throughout her time at Maryland, Clara Hill
has been highly involved in research, teaching, mentoring students, and
administration. In the early years, she also maintained a small private practice.
ACCOMPLISHMENTS
Therapy Process
Hill’s most abiding interest over the years has been in the investigation
of therapist techniques, following her conviction that what therapists do
in sessions indeed makes a difference. In examining therapist intentions,
for example, she found that clients were not very accurate in identifying such
intentions. Intriguingly, though, she also found that they need not be, for
therapy to be successful. Through her exploration of therapist response
CLARA E. HILL 155

modes, Hill discovered that although they do significantly affect the therapy
process, they do not account for a large proportion of the variance. A few spe-
cific response modes, however, were found to be most helpful: interpretation,
self-disclosure, paraphrase, and approval. As a complement to her work on ther-
apist response modes, Hill also investigated client reactions, developing a cod-
ing system that enabled researchers to capture covert client experiences,
particularly clients’ hidden negative reactions. Continued research using her
client behavior coding system revealed that clients responded differently to spe-
cific therapist interventions. After therapist interpretation, for instance, clients’
levels of experiencing and exploration of the therapy relationship increased.
Hill continued to pursue her fascination with the therapy process in her
later efforts, for she firmly believed that looking at specific interventions
within the context of clinical cases allowed for a better understanding of how
these interventions operate at specific times for specific clients than did
examining the overall effects of therapist interventions across all of therapy
and all clients. In this work, for example, she examined self-disclosure (Hill,
Mahalik, & Thompson, 1989; Knox, Hess, Petersen, & Hill, 1997), silence
(Hill, Thompson, & Ladany, 2003; Ladany, Hill, Thompson, & O’Brien,
2004), and immediacy (Hill, Sim, et al., 2008; Kasper, Hill, & Kivlighan,
2008). Using therapist self-disclosure as an illustration (see the review in Hill
& Knox, 2002), Hill found that although such disclosures were rare, their
frequency varied by theoretical orientation (e.g., humanistic/experiential
therapists disclosed more than did psychoanalytic therapists) and they were
perceived by clients as helpful in the short-term, although the longer term
effects remained unclear.
In addition to looking at specific therapist interventions, Hill also exam-
ined client insight (see Castonguay & Hill, 2007), a line of research arising from
her interest in how clients achieve these deeper understandings that she con-
siders central to therapy. In a series of studies exploring the development of
client insight within single sessions using Hill’s model of dream work, Hill and
colleagues (Hill et al., 2007; Knox, Hill, Hess, & Crook-Lyon, 2008) found that
insight developed when clients discussed moderately salient dreams in the con-
text of a solid therapy relationship, had positive attitudes toward dreams, were
ready for dream work and remained motivated throughout the dream session,
and were not overwhelmed by affect when discussing the dream. Insight was
also facilitated when therapists were competent with the dream model, success-
fully managed their countertransference, and used probes for insight.
Clara Hill’s plans for the near future involve integrating many of her
previous interests in studying ongoing therapy. She will investigate, for exam-
ple, the role of therapist interventions for working actively with the thera-
peutic relationship (immediacy, probes for insight, and interpretation) in
fostering insight and corrective relational experiences.
156 SARAH KNOX

Teaching Helping Skills
Given her career-long research interest in therapist techniques, as well

as her years of training therapists, Hill wrote a text on helping skills, now in
its second edition (Hill, 2004b; Hill & O’Brien, 1999), with the third edition
expected in 2009. Hill had been frustrated by the lack of helping skills texts
that integrated affect, cognition, and behavior as equally crucial elements in
the change process. Nor had she found texts that incorporated both theoret-
ical and empirical grounding for helping skills. Furthermore, Hill based Help-
ing Skills on her conceptualization of the helping process “as comprising
moment-by-moment interactional sequences”:
[A]t any moment in the helping process, helpers develop intentions for
how they want to help clients. . . . With these intentions in mind,
helpers select verbal and nonverbal skills with which to intervene. In
turn, clients react to the interventions in ways that influence how they
then choose to behave with helpers. Thus, helping involves not only the
overt behaviors but also the cognitive processes of helpers (i.e., inten-
tions) and clients (i.e., reactions). (Hill, 2004b, p. xviii)
The bulk of Helping Skills is devoted to the three stages of Hill’s integrated
helping skills model. Exploration, the first stage, is rooted in client-centered
theory; insight, the second stage, is based on psychoanalytic and interpersonal
theories; action, stage three, is built upon behavioral and cognitive theories.
For each stage, Hill presents helping skills appropriate for that stage (e.g., open
questions and restatements in exploration, challenges and interpretation in
insight, process advisement in action) and not only defines and provides exam-
ples of each skill but also addresses therapist intentions for the skill, possible
client reactions and behaviors evoked by the skill, and potential difficulties
encountered when using the skill. Each skill-based chapter closes with help-
ful hints for using the skill, written exercises, and a practice activity through
which students’ mastery of the skills may be enhanced. Thus, Helping Skills
not only provides excellent theoretical and empirical grounding for Hill’s
conceptualization of the helping process but also presents specific interven-
tions appropriate for each stage, thereby enabling students to learn both the
what and the how of counseling. Students find this text to be engaging and
user-friendly, and they feel comfortable using it as a good primer for learning
the basic skills and becoming empathic helpers.
Of course it was not enough just to propose a model of training. Hill next
devoted considerable effort to understanding the effects of training (see Hill
& Lent, 2006; Hill, Stahl, & Roffman, 2007). To facilitate this endeavor, she
developed measures of helping skills usage (Hill & Kellems, 2002) and coun-
selor self-efficacy (Lent, Hill, & Hoffman, 2003; Lent et al., 2006). Recent
CLARA E. HILL 157

studies have suggested the effectiveness of helping skills training for under-
graduates (Hill & Kellems, 2002; Hill, Roffman, et al., 2008), and another
described the experiences of master’s level students during their training (Hill,
Sullivan, Knox, & Schlosser, 2007).
Dreams
Another of Hill’s major accomplishments has been her work with

dreams. Long interested in dreams, both her own and those of her clients, she
also long believed that dreams hold important meanings that may be useful
in therapy. When teaching an undergraduate seminar on dreams several years
ago, Clara was especially drawn to Freudian, Jungian, and gestalt approaches
to dream interpretation. To her dismay, she found little, if any, evidence in
support of the various theories of dream interpretation. To pursue this area of
research, Hill developed a model of dream interpretation so that therapists in
her studies could follow a standard method.
In her two books in this area (Hill, 1996, 2004a), Hill explained her
model of dream work in therapy, one that integrates client-centered, psycho-
analytic, gestalt, and behavioral theories. As with her helping skills model,
the Hill dream model involves three stages. In the exploration stage, the ther-
apist helps the client explore several major images of the dream using four
structured, client-centered steps (DRAW: description, re-experiencing, asso-
ciations, and identifying waking life triggers). In the insight stage, the thera-
pist builds on the foundation established in the exploration stage to help the
client acquire insight into the dream. Finally, based on the understanding of
the dream acquired through the first two steps, therapist and client work
together in the action stage to develop ideas about how the client might
introduce desired changes in waking life.
Reviews of the roughly 25 studies of this dream model (Hill, 1996; Hill
& Goates, 2004; Hill & Spangler, 2007) clearly demonstrate the effective-
ness of working with dreams in therapy. In a number of studies, clients rated
the depth and working alliance of dream sessions more than a standard devi-
ation higher than they rated sessions of regular therapy. In addition, clients
reported gaining insight into their dreams, action ideas for what to do about
problems in waking life, and resolution of target problems reflected in dreams.
In addition, Hill and her colleagues found that clients with better attitudes
toward dreams tended to volunteer for dream work and that clients preferred
working with therapists to working alone on dreams. They have also found
support for all of the components of the model, for client involvement, and
for therapist adherence/competence in using the model. Hill’s next chal-
lenge in this area is learning more about how therapists use dream work in
ongoing therapy.
158 SARAH KNOX

Qualitative Research
Feeling constrained by the type of understanding about inherently com-

plex psychotherapy phenomena yielded by traditional quantitative approaches
(see Hill & Gronsky, 1984), Hill began to explore qualitative approaches as a
means of asking and answering questions about therapy. Because she found the
descriptions of existing qualitative methods difficult both to understand and
to implement, she and two colleagues (Hill, Thompson, & Williams, 1997)
developed consensual qualitative research (CQR) to “integrate the best features
of the existing methods and also be rigorous and easy to learn” (Hill et al., 2005,
p. 196).
CQR is based on researchers asking open-ended questions via a semi-
structured protocol (usually interviews), thereby allowing the collection of
consistent verbal data across a relatively small number of participants, as
well as the flexibility to deeply investigate individual experiences. The
inductive data analysis process involves several judges collaborating to
make all decisions about the data, thus promoting multiple perspectives on
the data. All judges discuss their understanding of the data until they reach
consensus, and at least one auditor reviews the work of the primary team
of judges. The final results are presented in the form of domains (topic
areas), core ideas (abstractions or paraphrases of participant data), and
cross-analysis (common themes that emerge within a domain across all
participants).
As a testament to the respect CQR has earned, 27 articles using this
method were published in the profession’s leading journals between 1994
and 2003 (the time span used by Hill et al., 2005, in their article review-
ing the status of the method); more have appeared since that time, as well.
Clearly, CQR answers a need for researchers seeking a clearly articulated,
rigorous, appropriately flexible means of closely examining individuals’
inner experiences—experiences that lie at the very heart of the therapy
process.
Leadership Contributions
Clara Hill’s mark on her profession has extended beyond the empirical,
training, and methodological realms. She has served as editor of leading jour-
nals in her field (Journal of Counseling Psychology; Psychotherapy Research) and
views this role as one in which she is afforded an opportunity to guide and
shape her profession. Hill clearly enjoys her role as editor and firmly believes
that she has an obligation to provide educational reviews that mentor authors
in improving their manuscripts. Hill was also elected to serve as president of
both the North American Chapter of the Society for Psychotherapy Research
CLARA E. HILL 159

(SPR) and the International Society for Psychotherapy Research and has
been highly involved in SPR both before and since her presidential terms. As
a more personal accomplishment, Clara notes that she and Jim have raised
two children, of whom they are very proud.
INFLUENCES
Hill has acknowledged the influence of many individuals on her

career. Notable colleagues have included those in the counseling psychol-
ogy program at the University of Maryland (Bruce Fretz, Charlie Gelso,
Mary Ann Hoffman, Bob Lent, and Karen O’Brien), as well as many col-
leagues from the Society for Psychotherapy Research (too many to list).
Given her career stage, Clara now mentors others more often than she is
mentored; many of these individuals have become frequent collaborators
(again, too many to list).
CONCLUSION
The facts, summarized in this chapter, of Clara Hill’s contributions to

her profession are undeniably remarkable. No less remarkable, however, is
the pattern that lies behind these observable accomplishments and their
legacy. In each case, Hill identified a problem—a need to understand some-
thing in a new way, the lack of an existing research method to pursue that under-
standing, the limitations of extant tools for teaching the skills of therapy—and
then sought to solve that problem, doing so with tremendous success. Her
openness not only to being challenged by others but also to challenging her-
self has led to contributions noteworthy in both their quantity and quality.
Her work is thus proactive, forward thinking, and forward moving, and in her
demanding of herself that she continue to seek, to learn, and to create, she
stimulates her colleagues to do the same. Though she has many a laurel upon
which she could deservedly rest, Clara’s unwillingness to do so is one of her
greatest gifts to her profession.
REFERENCES
Carkhuff, R. R. (1969). Human and helping relations (2 vol.). New York, NY: Holt,
Rinehart & Winston.
Castonguay, L., & Hill, C. E. (Eds.). (2007). Insight in psychotherapy. Washington,
DC: American Psychological Association. doi:10.1037/11532-000
160 SARAH KNOX

Hill, C. E. (1996). Working with dreams in psychotherapy. New York, NY: Guilford Press.
Hill, C. E. (Ed.). (2004a). Dream work in therapy: Facilitating exploration, insight, and
action. Washington, DC: American Psychological Association. doi:10.1037/
10624-000
Hill, C. E. (2004b). Helping skills: Facilitating exploration, insight, and action
(2nd ed.). Washington, DC: American Psychological Association. doi:10.1037/
10624-000
Hill, C. E., & Goates, M. K. (2004). Research on the Hill cognitive-experiential
dream model. In C. E. Hill (Ed.), Dream work in therapy: Facilitating exploration,
insight, and action (pp. 245–288). Washington, DC: American Psychological
Hill, C. E., & Gronsky, B. (1984). Research: Why and how? In J. M. Whiteley,
N. Kagan, L. W. Harmon, B. R. Fretz, & F. Tanney (Eds.), The coming decade
in counseling psychology (pp. 149–159). Schenectady, NY: Character Research
Press.
Hill, C. E., & Kellems, I. S. (2002). Development and use of the Helping Skills Mea-
sure to assess client perceptions of the effects of training and of helping skills in
sessions. Journal of Counseling Psychology, 49, 264–272. doi:10.1037/0022-
0167.49.2.264
Hill, C. E., & Knox, S. (2002). Self-disclosure. In J. C. Norcross (Ed.), Psycho-
(pp. 255–265). Oxford, England: Oxford University Press.
Hill, C. E., Knox, S., Hess, S., Crook-Lyon, R., Goates-Jones, M., & Sim, W. (2007).
The attainment of insight in the Hill dream model: A single case study. In
L. Castonguay & C. E. Hill (Eds.), Insight in psychotherapy (pp. 207–230). Wash-
ington, DC: American Psychological Association. doi:10.1037/11532-010
Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S., & Ladany, N. (2005).
Consensual Qualitative Research: An update. Journal of Counseling Psychology,
52, 196–205.
Hill, C. E., & Lent, R. W. (2006). Training novice therapists: Skills plus. Psycho-
therapy Bulletin, 41, 11–16.
Hill, C. E., Mahalik, J. R., & Thompson, B. J. (1989). Therapist self-disclosure.
Psychotherapy: Theory, Research, Practice, Training, 26, 290-295. doi: 10.1037/
h0085438
Hill, C. E., & O’Brien, K. (1999). Helping skills: Facilitating exploration, insight, and
action [Video included]. Washington, DC: American Psychological Association.
Hill, C. E., Roffman, M., Stahl, J., Friedman, S., Hummel, A., & Wallace, C. (2008).
Helping skills training for undergraduates: Outcomes and predictors of out-
comes. Journal of Counseling Psychology, 55, 359–370.
Hill, C. E., Sim, W., Spangler, P., Stahl, J., Sullivan, C., & Teyber, E. (2008). Ther-
apist immediacy in brief psychotherapy: Case study II. Psychotherapy: Theory,
Research, Practice, Training, 45, 298–315.
CLARA E. HILL 161

Hill, C. E., & Spangler, P. (2007). Dreams and psychotherapy. In D. Barrett &
P. McNamara (Eds.), The new science of dreaming (pp. 159–186). Westport, CT:
Greenwood.
Hill, C. E., Stahl, J., & Roffman, M. (2007). Training novice therapists: Helping skills
and beyond. Psychotherapy: Theory, Research, Practice, Training, 44, 364–370.
Hill, C. E., Sullivan, C., Knox, S., & Schlosser, L. (2007). Becoming therapists: The
experiences of pre-practicum trainees. Psychotherapy: Theory, Research, Practice,
Training, 44, 434–449.
Hill, C. E., Thompson, B. J., & Ladany, N. (2003). Therapist use of silence in therapy:
A survey. Journal of Clinical Psychology, 59, 513–524. doi:10.1002/jclp.10155
Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consen-
sual qualitative research. The Counseling Psychologist, 25, 517–572. doi:10.1177/
0011000097254001
Kasper, L., Hill, C. E., & Kivlighan, D. (2008). Therapist immediacy in brief psycho-
therapy: Case study I. Psychotherapy: Theory, Research, Practice, Training, 45,
281–297.
Knox, S., Hess, S., Petersen, D., & Hill, C. E. (1997). A qualitative analysis of client
perceptions of the effects of helpful therapist self-disclosure in long-term therapy.
Journal of Counseling Psychology, 44, 274–283. doi:10.1037/0022-0167.44.3.274
Knox, S., Hill, C. E., Hess, S., & Crook-Lyon, R. (2008). The attainment of insight
in the Hill dream model: Replication and extension. Psychotherapy Research, 18,
200–215.
Ladany, N., Hill, C. E., Thompson, B. J., & O’Brien, K. M. (2004). Therapist per-
spectives on using silence in therapy: A qualitative study. Counselling & Psycho-
therapy Research, 4, 80–89. doi:10.1080/14733140412331384088
Lent, R. W., Hill, C. E., & Hoffman, M. A. (2003). Development and validation of
the Counselor Activity Self-Efficacy Scales. Journal of Counseling Psychology, 50,
97–108. doi:10.1037/0022-0167.50.1.97
Lent, R. L., Hoffman, M. A., Hill, C. E., Treistman, D., Mount, M., & Singley, D.
(2006). Client-specific counselor self-efficacy in novice counselors: Relation to
perceptions of session quality. Journal of Counseling Psychology, 53, 453–463.
doi:10.1037/0022-0167.53.4.453
162 SARAH KNOX

B. CLIENT CONTRIBUTIONS
14
EUGENE GENDLIN: EXPERIENTIAL
PHILOSOPHY AND PSYCHOTHERAPY
DAVID L. RENNIE, ARTHUR C. BOHART, AND ALBERTA E. POS
Eugene Gendlin is one of the most influential thinkers in the person-

centered/experiential psychotherapy world. Trained in philosophy, he turned
to the field of psychotherapy early in his career and has participated in both
fields since. Throughout, his interest has been the process of lived experience,
or active experiencing. Upon his joining Carl Rogers’s team at the Counsel-
ing Center of the University of Chicago, Gendlin’s notion of experiencing
enriched the Rogerian concept of therapeutic change. Subsequently, Gendlin
contributed to the development of the Experiencing Scale, a much-used
instrument in psychotherapy research. He also contributed substantially to
psychotherapy process research. He directed and participated in Rogers’s
schizophrenia research project at the University of Wisconsin and did inde-
pendent research on the relations between levels of experiencing and indi-
cators of stress as well. He later developed a unique approach to therapy
organized in terms of focusing on embodied experiencing, practiced around
the world. He has also created a new philosophy based on embodied expe-
riencing. In what follows, after attending to his early beginnings, we sum-
marize this philosophy and Gendlin’s contributions to psychotherapy theory,
165
EARLY BEGINNINGS
Gendlin was born in Vienna, Austria, in 1926. Being Jewish, the family
fled the Nazis to the United States in 1939. Gendlin enrolled in the Depart-
ment of Philosophy at the University of Chicago, where he developed a method
of accepting a given system of thought in its entirety and then trying to for-
mulate any point in terms of the ideas and symbols from within that system
(see Gendlin, 1988). What interested him was that even though alternative
systems entailed differing formulations and implications, there was never-
theless a sameness that cut across the systems. Meanwhile, he did his master’s
thesis on the philosophy of Wilhelm Dilthey (see, e.g., Makkreel, 1992), who
challenged Enlightenment rationalist thought through his emphasis of the
importance of Erlebnis, generally translated as “lived experience.” This
emphasis led Gendlin to the role of the body in felt experiencing of some-
thing, whence came the notion of an underlying sameness conceptualized
as embodied experiencing, which became the linchpin of his thought.
Gendlin received his PhD in philosophy from the University of
Chicago in 1958, under the mentorship of Richard McKeon. Around that
time he became interested in psychotherapy because he saw it as involving
the process of symbolizing experiencing freshly. He joined Rogers’s team
at the Counseling Center there, later moving with the team to the Uni-
versity of Wisconsin, where Gendlin directed the team’s schizophrenia
research project. Later he joined the Psychology Department at the Uni-
versity of Chicago, during which time he also founded the Focusing Institutes
in Chicago and Spring Valley, New York, offering training in focusing and
focusing-oriented psychotherapy.
ACCOMPLISHMENTS
Theory: Experiential Phenomenological Philosophy
Gendlin has developed a philosophy that he calls experiential phenome-

nology, formulated to take into account the body as a source of meaning.
Gendlin first presented his philosophy in a seminal work, Experiencing and the
Creation of Meaning (Gendlin, 1962), and has continued to develop it (e.g.,
Gendlin, 1997, 2001). His philosophy is too sophisticated to be depicted ade-
quately here (for details, see, e.g., Levin, 1997; for brief interpretations by
psychologists, see Pos, Greenberg, & Elliott, 2008; Rennie & Fergus, 2006).
However, the gist of it is that, along with Heidegger and that minority of the
contemporary philosophers who challenge the currently common emphasis
on rationalism, Gendlin insists that the body plays an important role in how
166 RENNIE, BOHART, AND POS

people create meaning out of experience. This is so because in any lived
event, one’s embodied experiencing is a consistent source of implicit know-
ing, in that bodily states reflect several overlapping processes (e.g., physiolog-
ical, sensory-motor, relational); thus, implicit body-based meaning is full of
potential implications and “may have countless organized aspects” (Gendlin,
1964, p. 140).
Accordingly, Gendlin proposes that bodily experiencing entails
an implicit intricacy in any problematic situation. Although this implicit
intricacy often seems vague—more like a felt sense of some kind—it is
nevertheless a finely ordered complexity. If we attend to and symbolize
(in words, images, etc.) this felt sense, its meaning will come to us. In
this process, only the right symbols, those that fit the felt sense well, will
do. When we come up with a fit that feels right, our experiencing changes;
we move a step forward toward resolving the situation. The process usually
proceeds through a series of steps. What the person turns to in each step
usually is not a matter of logical deduction, although it logically makes
sense in retrospect. Overall, experience is best thought of as experiencing—
an ongoing process (Gendlin, 2001). Gendlin sees clients’ working with
their experiencing in psychotherapy as an excellent example of this
process.
A word about Gendlin’s philosophy of science: He maintains that phi-
losophy is more abstract than science and operates on a different level. As a
scientist, he endorses positivism, asserting that it can and should be improved
by creating concepts through focusing on the implicit intricacy of phenom-
ena, rather than by making the intricacy conform to concepts drawn from the
externalizing logical order (Gendlin, 1962, 1991). His psychotherapy research
has reflected this principle.
Psychotherapy Research
Two prominent research areas, on the process of clients’ experiencing

and on focusing as a therapeutic intervention, have emerged as a result of
Gendlin’s work.
Understanding and Working With Clients’ Experiencing

Generally, conclusions from research on clients’ experiencing suggest
that (a) higher clients’ experiencing predicts good session and overall out-
come, and this has proved to apply to a number of therapy modalities and
populations; (b) clients’ early therapy experiencing levels often predict out-
come; (c) improving clients’ experiential processing during experiential ther-
apy predicts outcome better than clients’ beginning therapy levels of such
EUGENE GENDLIN 167

processing; (d) other therapy processes, such as the therapeutic alliance in
experiential therapy and good interpretations in dynamic therapy, contribute
to deeper client experiencing; (e) focusing as an intervention increases
clients’ experiencing; and (f) some mixed results have been found.
Research on client experiencing began when Gendlin joined Rogers’s
team. Rogers’s group had just completed a study on psychotherapy processes
relating to positive therapeutic outcome. The hypothesis that clients’ talking
about the present rather than the past would relate to positive outcomes was
not supported; however, how clients talked—whether they expressed their
feelings or simply talked about them (Seeman, 1954)—did correlate with out-
come. Gendlin, Jenney, and Shlien (1960) then redid the study, adding two
psychotherapy process measures in an attempt to answer two new questions:
(a) How important to the client is the relationship as a source of new experi-
ence? and (b) To what extent does the client express his or her feelings rather
than talk about them? Both supplemental measures were found to correlate
with positive outcome.
Gendlin and Berlin (1961) then tested whether focusing on experience
would lead to tension reduction. One group of undergraduates received
instructions to focus on their experiencing of strong, troublesome feelings,
while other groups were instructed either to attend continuously to an exter-
nal object or discontinuously to internal sensations different from troubling
feelings. The group that focused on experiencing showed more tension reduc-
tion compared with the groups in other conditions. This study anticipated
several others demonstrating a relationship between experiencing and phys-
iological responsiveness (e.g., Don, 1977).
Under Gendlin’s influence, the Process Scale developed by Walker,
Rablen, and Rogers (1960) was refined into the Experiencing Scale (Klein,
Mathieu, Gendlin, & Kiesler, 1969). The Experiencing Scale measures the
degrees to which clients’ in-session narratives demonstrate that they are ori-
enting to and symbolizing their felt internal experiencing and using it in the
solving of their problems. The scale measures seven levels of experiencing in
terms of grammatical, expressive, paralinguistic, and content criteria. At
Level 1 clients’ narratives are objective and intellectual, showing no con-
nection with or evidence of the personal significance of events described;
at Level 7, as summarized by Gendlin (personal communication, October,
2007), clients tell very personal stories moving from “one direct experiential
referent and speech to the next direct referent and speech.”
Much discussion has gone on about what dimensions the Experiencing
Scale actually measures. Lambert and Hill (1994) maintained that it is multi-
dimensional, that it emphasizes emotional expressiveness rather than cogni-
tive expression, and that it is unclear whether a high score on the scale

indicates insight or involvement. In contrast, Wexler (1974) found that the
scale correlated more with cognitive than with emotional factors, whereas
Klein, Mathieu-Couglan, and Kiesler (1986) concluded that the Experienc-
ing Scale is a measure of reflective style. Meanwhile, Gendlin has always held
that experiencing is a felt sense much broader than emotion. Therefore, it may
be supposed that from Gendlin’s perspective the Experiencing Scale measures
the degree of integration between clients’ capacities both to experience
embodied feeling states and to process cognitively (with awareness and con-
ceptual symbolization) the personal information implicit within those states.
In 1968 Gendlin et al. evaluated extant research on the relationship
between neurotics’ and schizophrenics’ experiencing and outcome and deter-
mined that the relationship was positive. Contrary to prediction, however,
“half the clients were failure-predicted from the first interviews at .001 signif-
icance, which meant so much work, love, and money predictably was wasted”
(E. Gendlin, personal communication, October, 2007). Also, on the whole,
experiencing did not appear to increase over the course of psychotherapy.
This finding was contrary to a key hypothesis held by the Rogerian group that
psychotherapy helps clients move from a rigid, structure-bound manner of
experiencing to a more fluid and internally congruent one.
Shifts from lower to higher levels of experiencing were expected to cor-
relate with outcome in therapy. Kiesler, Klein, and Mathieu (1965) found
some support for this hypothesis, finding an upward trend during a therapy
hour with neurotics, although with schizophrenics the pattern was more irreg-
ular. On the whole, though, the team engaged in the Wisconsin Schizophre-
nia Project concluded that for both schizophrenics and neurotics, the level of
experiencing changed only minimally over the course of therapy. The initial
level of their experiencing was more important than change in the manner of
it. Clients who benefited from therapy entered it already high in experiencing.
Since then, more support for the original hypothesis has been established with
respect to nonpsychotic clients. A series of studies of process–experiential
therapy have demonstrated that increases in experiencing levels actually occur
and better predict positive outcome than do clients’ initial early therapy expe-
riencing levels (Goldman, Greenberg, & Pos, 2005; Greenberg & Higgins,
1980; Pos et al., 2003; Pos, Greenberg, & Warwar, in press).
Meanwhile, other therapy processes appear to be related to client expe-
riencing. Pos, Greenberg, and Warwar (in press) found that the therapy
alliance contributes to the deepening of experiencing during emotion episodes
in successful experiential treatment of depression. More generally, it has also
been shown that good psychoanalytic interpretations, gestalt therapy, guided
daydreams, encounter group training, and reevaluation counseling all increase
clients’ pre- and posttherapy experiencing compared with controls (Elliott,
EUGENE GENDLIN 169

Greenberg, & Lietaer, 2004), whereas Bohart (2001) has applied the concept
of experiencing to self-healing.
Research has also shown mixed results, however. Hendricks (2002)
found in a review of 29 studies entailing the Process Scale and the Experi-
encing Scale that 27 demonstrated positive correlations with outcome. In
contrast, Orlinsky, Grawe, and Parks (1994) and Orlinsky, Rønnestad, and
Willutzki (2004) gave a more mixed picture in which, among 39 effects
distributed among a number of studies, 51% were positive.
Focusing and Focusing-Oriented Psychotherapy

The focusing technique and focusing-oriented psychotherapy are two
major developments that came out of research on experiencing. To address
the early research findings showing little evidence that experiencing level
increases in therapy, Gendlin (1981) developed a technique for teaching
clients to focus, the idea being that this would increase the probability of
success in psychotherapy. The technique entails six basic steps, beginning
with “Clearing a space. Focus attention inwardly and try to become recep-
tively aware and welcome what is inside” and ending with “Receiving.
Receive whatever arises in a friendly, accepting way.” A number of studies
have demonstrated that focusing can indeed be taught (Clark, 1980; Gendlin,
1981), although the effectiveness of the teaching (Durak, Bernstein, &
Gendlin, 1997) and the durability of what was learned (Leijssen, 1996;
Liejssen, Leitaer, Stevens, & Wels, 2000; see also Hendricks, 2002) were
found to vary.
In addition to its application in individual (Gendlin, 1981, 1996b) and
group (see http://www.focusing.org/gendlin/) therapy, self-help manuals,
developed not only for psychotherapy clients but for anyone, have been based
on the focusing technique (Gendlin, 1981). Moreover, it is used in other
approaches, such as process–experiential therapy (Elliott, Greenberg, &
Lietaer, 2004), discussed in the previous section, and eye movement desensi-
tization and reprocessing (Francine Shapiro, personal communication to Art
Bohart, 2000). Meanwhile, it has been shown that it is useful to train thera-
pists to engage in focusing (e.g., Swaine, 1986). Moreover, it has been related
to positive outcome in therapy, thus paralleling experiencing, as would be
expected. It was found, for example, that learning to focus was related posi-
tively both to the effectiveness of client-centered therapy sessions and early,
successful termination of therapy (Leijssen, 1996); to successful outcome with
people with psychoses (Egendorf & Jacobson, 1982); to improved memory in
older people (Sherman, 1987); and among patients with cancer currently in
remission, to improved self-ratings of symptoms as well as improved scores
on measures of personality (Katonah, 1991).

OTHER CONTRIBUTIONS
Gendlin published, in 1986, an influential article on the psychotherapy

research agenda for the future, proposing 18 strategies. To give their flavor,
his first suggestion is that therapists should routinely tape record their cases,
measure variables before and after treatment, and send clearly successful cases
to a data bank. In virtue of the increase in the present-day valuing of case his-
tory as method and the emphasizing of practice-based evidence, Gendlin was
prescient. Another example is his fourth suggestion, that psychotherapy
should be evaluated in terms of ongoing therapy process instead of through
group-design research. He puts out a call to make it the order of the day to
study how subprocesses work well, not just in therapy but in all aspects of life.
He was among the founders of both the journal of the Psychotherapy
Division of the American Psychological Association (APA) and the group
Psychologists for Social Responsibility. He also formed the International
Focusing Society, which does training of focusing throughout the world. He
is the author of several books that have become classics. He has influenced
many theoreticians and researchers. For his contributions he has been pre-
sented with a Distinguished Professional Psychology Award by APA, a related
award by APA’s Society of Humanistic Psychology, and the Grand Award of
the Victor Frankl Foundation by the city of Vienna.
CONCLUSION
Eugene Gendlin is a major founder of the general humanistic/experiential/

person-centered approach to psychotherapy. Moreover, his lifelong work on
experiencing and the creation of meaning is drawing increasing attention in
philosophy (see Levin, 1997) and has played a central role in the conceptu-
alization of the therapeutic process. The production of the Experiencing
Scale, in expression of his theory of experiencing, continues to be used exten-
sively. His technique of having clients engage in focusing in therapy has been
incorporated into many approaches to therapy apart from Gendlin’s partic-
ular use of it. Gendlin is a model of someone who can make a theory of the
person work hand in hand with psychotherapy research and practice.
REFERENCES
Bohart, A. (2001). A meditation on the nature of self-healing and personality change

in psychotherapy based on Gendlin’s theory of experiencing. Humanistic Psycho-
logist, 29, 249–279.
EUGENE GENDLIN 171

Clark, D. B. (1980). Effects of experiential focusing with psychotherapy patients.
Dissertation Abstracts International, 41(2-B), 684. (University Microfilms
No. 8017688).
Don, N.S. (1977). Transformation of conscious experience and its EEG correlates.
Journal of Altered States of Consciousness, 3, 147–168.
Durak, G. M., Bernstein, R., & Gendlin, E. T. (1997). Effects of focusing training
on therapy process and outcome. Folio: A Journal for Focusing and Experiential
Therapy, 15(2), 7–14.
Egendorf, A., & Jacobson, L. (1982). Teaching the very confused how to make sense:
An experiential approach to modular training with psychotics. Psychiatry, 45,
336–350.
Elliott, R., Greenberg, L. S., & Lietaer, G. (2004). Research on experiential psycho-
therapies. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy
and behavior change (5th ed., pp. 493–540). New York, NY: Wiley.
Gendlin, E. T. (1962). Experiencing and the creation of meaning. New York, NY: Free
Press of Glencoe, Macmillan.
Gendlin, E. T. (1964). Personality change. In P. Worchel & D. Byrne (Eds.), A theory
of personality change (pp. 102–148). New York, NY: Wiley.
Gendlin, E. T. (1981). Focusing (2nd ed.). New York, NY: Bantam.
Gendlin, E. T. (1986). What comes after traditional psychotherapy research? Amer-
ican Psychologist, 41, 131–136. doi:10.1037/0003-066X.41.2.131
Gendlin, E. T. (1988). Phenomenology as non-logical steps. In E. F. Kaelin & C. O.
Schrag (Eds.), Analecta Husserliana: The yearbook of phenomenological research:
Vol. XXVI. American phenomenology: Origins and developments (pp. 404–410).
Dordrecht, Holland/Boston, MA: Kluwer.
Gendlin, E. T. (1991). Thinking beyond patterns: Body, language, and situations. In
B. den Ouden & M. Moen (Eds.), The presence of feeling in thought (pp. 21–151).
New York, NY: Peter Lang.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy. New York, NY: Guilford.
Gendlin, E. T. (1997). How philosophy cannot appeal to experience, and how it can.
In D. M. Levin (Ed.), Language beyond postmodernism: Saying and thinking in
Gendlin’s philosophy (pp. 3–41). Evanston, IL: Northwestern University Press.
Gendlin, E. T. (2001). A process model. http://www.focusing.org/postmod.htm.
Gendlin, E. T., & Berlin, J. I. (1961). Galvanic skin response correlates of different
modes of experiencing. Journal of Clinical Psychology, 17, 73–77. doi:10.1002/
1097-4679(196101)17:1<73::AID-JCLP2270170128>3.0.CO;2-Y
Gendlin, E. T., Jenney, R., & Shlien, J. M. (1960). Counselor ratings of process and
outcome in client-centered therapy. Journal of Clinical Psychology, 16, 210–213.
doi:10.1002/1097-4679(196004)16:2<210::AID-JCLP2270160228>3.0.CO;2-J
Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional expe-
rience and outcome. Psychotherapy Research, 15, 248–260. doi:10.1080/
10503300512331385188

Greenberg, L. S., & Higgins, H. M. (1980). The differential effects of two-chair dia-
logue and focusing on conflict resolution. Journal of Counseling Psychology, 27,
221–224. doi:10.1037/0022-0167.27.3.221
Hendricks, M. N. (2002). Focusing-oriented/experiential psychotherapy. In D. Cain
& J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and prac-
tice (pp. 221–251). Washington, DC: American Psychological Association.
doi:10.1037/10439-007
Katonah, D. G. (1991). Focusing and cancer: A psychological tool as an adjunct treat-
ment for adaptive recovery. Unpublished doctoral dissertation, Illinois School
of Professional Psychology, Chicago, IL. Available at http://www.focusing.org/
adjunct_treatment.html
Kiesler, D. J., Klein, M. H., & Mathieu, P. L. (1965). Sampling from the recorded
therapy interview: The problem of segment location. Journal of Consulting Psy-
chology, 29, 337–344. doi:10.1037/h0022422
Klein, M. H., Mathieu, P. L., Gendlin, E. T., & Kiesler, D. J. (1969). The Experienc-
ing Scale: A research training manual. Madison, WI: University of Wisconsin
Extension Bureau of Audiovisual Instruction.
Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986). The Experiencing
Scales. In L. S. Greenberg & W. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 21–71). New York, NY: Guilford.
Lambert, M. J., & Hill, C. E. (1994). Assessing psychotherapy outcomes and processes.
In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior
change (4th ed., pp. 72–113). New York, NY: Wiley.
Leijssen, M. (1996). Characteristics of a healing inner relationship. In R. Hutterer,
G. Pawlowsky, P. F. Schmid, & R. Stipsits (Eds.), Client-centered and experiential
psychotherapy: A paradigm in motion (pp. 427–438). Frankfurt am Main, Germany:
Peter Lang.
Leijssen, M., Lietaer, G., Stevens, I., & Wels, G. (2000). Focusing training in stag-
nating clients: An analysis of four cases. In J. Marques-Teixeira & S. Antunes
(Eds.), Client-centered and experiential psychotherapy (pp. 207–224). Linda a
Velha, Portugal: Vale & Vale.
Levin, D. M. ((Ed.). 1997). Language beyond postmodernism: Saying and thinking in
Gendlin’s philosophy. Evanston, IL: Northwestern University Press.
Makkreel, R. A. (1992). Dilthey: Philosopher of the human studies. Princeton, NJ:
Princeton University Press.
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psycho-
therapy: Noch einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of
psychotherapy and behavior change (4th ed., pp. 270–376). New York, NY: Wiley.
Orlinsky, D. E. Rønnestad, & Willutzki, U. (2004). Fifty years of psychotherapy
process-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin
and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307–390).
EUGENE GENDLIN 173

Pos, A. E., Greenberg, L., & Elliott, R. (2008). Experiential therapy. In J. Lebow (Ed.),
Twenty-first century psychotherapies (pp. 80–122). New York, NY: Wiley.
Pos, A. E., Greenberg, L. S., Goldman, R. N., & Korman, L. M. (2003). Emotional
processing during experiential treatment of depression. Journal of Consulting and
Pos, A. E., Greenberg, L. S., & Warwar, S. H. (2009). Testing a model of change in
experiential treatment of depression. Journal of Consulting and Clinical Psychology,
77, 1055–1066.
Rennie, D. L., & Fergus, K. D. (2006). Embodied categorizing in the grounded theory
method: Methodical hermeneutics in action. Theory & Psychology, 16, 483–503.
doi:10.1177/0959354306066202
Seeman, J. (1954). Counselor judgments of therapeutic process and outcome. In
C. R. Rogers & R. Dymond (Eds.), Psychotherapy and personality change. Chicago,
IL: University of Chicago Press.
Sherman, E. (1987). Reminiscence groups for community elderly. Gerontologist, 27,
569–572.
Swaine, W. T. (1986). Counselor training in experiential focusing: Effects on
empathy, perceived facilitativeness and self-actualization. Dissertation Abstracts
International, 47(4-A), 1197.
Walker, A., Rablen, R. A., & Rogers, C. R. (1960). Development of a scale to mea-
sure process change in psychotherapy. Journal of Clinical Psychology, 1, 79–85.
doi:10.1002/1097-4679(196001)16:1<79::AID-JCLP2270160129>3.0.CO;2-K
Wexler, D. A. (1974). A cognitive theory of experiencing, self-actualization, and
therapeutic process. In D. A. Wexler & L. N. Rice (Eds.), Innovations in client-
centered therapy (pp. 49–116). New York, NY: Wiley.

15
LAURA RICE: NATURAL OBSERVER
OF PSYCHOTHERAPY PROCESS
JEANNE C. WATSON AND HADAS WISEMAN
Laura Rice was a pioneer of psychotherapy process research. With

boundless curiosity, she was a keen observer of the natural world. Rice
completed her doctoral studies at the University of Chicago in 1955, under
the supervision of Jack Butler. It was in her work at the University of
Chicago, with Carl Rogers and colleagues, that she brought together her
passion for helping others with her curiosity and desire to do research.
Schooled in client-centered therapy, she went on to develop the theory
and practice of this approach based on cognitive science and her own
understanding of psychotherapy process derived from her clinical experi-
ence as well as her research on patterns of change in psychotherapy. Sub-
sequently, she developed process–experiential psychotherapy with Leslie
Greenberg and Robert Elliott.
Laura Rice embodied the research clinician, successfully integrating
theory, research, and practice to inspire her students and future generations
to engage in psychotherapy process research. In the 1980s, Carl Rogers rec-
ognized her as a major contributor to research in client-centered therapy, and
in 1988 the Society for Psychotherapy Research acknowledged her contribu-
tions to the field with the Distinguished Research Career Award.
175
MAJOR CONTRIBUTIONS
The primary focus of Rice’s work was to identify the mechanisms of

change and the active ingredients of client-centered therapy. She made
important contributions to client-centered theory and practice: first, by con-
ceptualizing change in terms of clients’ cognitive–affective functioning; and
second, by distinguishing between the relationship conditions and the task
conditions (Rice, 1974, 1983). In terms of theory, Rice, in her work with
Butler (Butler & Rice, 1963), proposed that stimulus hunger or adient moti-
vation was a primary drive and the basis of organismic self-actualization, a
central tenet of Rogers’s theory of personality. They argued that adience or
stimulus hunger, the basis of exploratory behavior and the organism’s prefer-
ence for complexity, facilitated development. Stimulus hunger was seen as
stronger than the maintenance drives, such as those for food and water.
According to these theorists, dysfunctional behavior reflected the organ-
ism’s attempt to restrict experiences, thereby limiting its capacity for self-
actualization (Butler, Rice, & Wagstaff, 1963). Thus the goal of therapy was
to reduce anxiety and enable the organism to explore hisor her environment
to open up new possibilities and ways of being. Rice, like Rogers, believed that
the individual’s capacity for self-actualization could be activated in therapy
so that clients could search for solutions to life problems with the support of
their therapists (Rice, 1984).
Like many researchers today, Rice was disillusioned with psychotherapy
outcome studies, because she did not see them as furthering understanding of
client change. Instead, she turned her attention to identifying and under-
standing the resources that clients bring to therapy (Rice, 1992). She pro-
posed a method of naturalistic observation, independent of theory, to identify
client characteristics and resources, related to good and poor outcome. Then
she examined how therapists’ processes influenced clients’ processes. These
two foci resulted in the development of a number of therapist and client
process measures, including client and therapist vocal quality and expressive
stance (Rice & Kerr, 1986).
Rice’s intense observation of the psychotherapy process enabled her to
identify and explicate different types of change events in client-centered ther-
apy (Rice & Greenberg, 1991). Using task analysis, she and Greenberg (1984)
described and explicated the steps that therapists and clients engage in to
resolve specific cognitive–affective problems in therapy, for example, helping
clients to understand intense reactions or resolve states of intense vulnerabil-
ity in a session. The primary objective of this work was to create microtheories
of change that would enable therapists to intervene differentially at specific
client markers to maximize the match between client and therapist resources.
Another important contribution was Rice’s distinction between primary and
176 WATSON AND WISEMAN

task-relevant relationship factors. While Rice saw the therapeutic conditions
specified by Rogers as important in promoting client change, she thought ther-
apists could do more to facilitate optimal conditions for certain kinds of client
exploration (Rice, 1984). Her emphasis on therapist-directed process notwith-
standing, Rice viewed the client as the expert on his or her own experiences.
Convinced that a common language was essential to advance the sci-
ence of psychotherapy, Rice (1974, 1992) adopted a cognitive information-
processing paradigm to understand and explain the complex processes of
change. She criticized client-centered theory as focusing too much on the
self concept and not enough on the individual’s perceptions of and transac-
tions with the world. Rice proposed that change in therapy occurred through
alterations to clients’ perceptual cognitive–affective frameworks and self-
schemas. She suggested that client-centered therapy provided clients with
the opportunity to become aware of their affective experiences and to explore
them to create new experiences and ways of viewing self and other.
EARLY BEGINNINGS
Laura Rice was born in 1920, in New England, to parents of Puritan

descent. Her father, whom Rice experienced as distant and critical, was a
lawyer. Both her parents were intellectuals who home-schooled their chil-
dren to ensure the quality of their education, so Laura was in her early teens
before she attended public school. She later expressed regret that she had
been cloistered at home as a child, as it left her with a sense of being out of
step with her peers.
Rice’s life was filled with personal tragedy. Both her brother and fiancé
were killed during World War II, and she never quite recovered from those
losses. More tragedy was to follow. As a close friend and companion to her
sister throughout her life, Rice took much pride and pleasure in her role as
aunt to her nephew and niece, who both died from cancer as young adults.
Subsequently, Rice took comfort and found joy in her role as great-aunt to
her nephew’s son, with whom she spent vacations when he visited his grand-
parents during the summer.
Rice initially wanted to study botany; however, she switched to psychol-
ogy and devoted her life to counseling others and to understanding and
researching psychotherapy processes and outcomes, first at the University of
Chicago and then at York University in Toronto. Prior to beginning her doc-
toral studies, Rice worked in human resources for an airline company con-
ducting aptitude and cognitive assessments for pilots and other employees.
She resigned from this position and returned to the University of Chicago to
begin her doctoral studies in 1951. She gave two reasons for choosing the
LAURA RICE 177

University of Chicago: The Psychology Department offered, first, “an excel-
lent program in theoretical psychology with a strong research focus,” and, sec-
ond, the presence on faculty of Carl Rogers, who was engaged in process
research and whose book Client-Centered Therapy (Rogers, 1951) had just
been published.
After graduating with her PhD from Chicago in 1955, Laura Rice
worked at and later directed the Counselling Centre before moving to
Toronto in 1970 to take up a faculty position at York University. She
retained her early interest in plants and animals with a hobby farm just out-
side of Toronto, where she kept a horse and cultivated strawberries and
other produce. On weekends the farm provided her with a retreat from the
demands of the city, her clients at the University Counselling Centre, and
students. Rice retired from York University in 1986; however, she stayed
on as professor emeritus for another 6 years. In 1993, she returned to Mas-
sachusetts to be close to her sister and extended family. She died on July
18, 2004, at the age of 84.
ACCOMPLISHMENTS
Process Research Methods: Quantitative Naturalistic Research Program
Rice was an innovator of research methodologies (Rice, 1992). At

the University of Chicago in the late 1950s and early 1960s, with Butler
and Wagstaff, she began a research program, supported by the National
Institute of Mental Health (NIMH), to investigate the psychotherapy
process (Butler, Rice, & Wagstaff, 1963). They initiated a time-limited
psychotherapy program to collect data and proposed the use of a quantita-
tive naturalistic research methodology to generate groups of process cate-
gories to develop testable hypotheses that emerged from intense observation,
independent of theory.
Initially, Rice (1965) attempted to classify the vocal and lexical aspects
of therapists’ styles of participation during the session (Duncan, Rice, &
Butler, 1968; Rice & Wagstaff, 1967). She identified three aspects of thera-
pist style: the type of language used, fresh and connotative or ordinary; vocal
quality in terms of whether it was expressive, usual, or distorted; and the
stance that therapists adopted toward the clients’ experience in terms of
whether it was focused on inner exploration, observation, or analysis. Inter-
views were then classified in terms of the frequency of these behaviors. Three
different interview types were identified: Type 1 was characterized by common-
place language and an even, unexpressive vocal quality, with responses focused
on client-self observation; Type 2 was characterized by little connotative lan-

guage and distorted vocal quality; with a focus on client self-observation
and few attempts to encourage inner exploration; Type 3, in contrast, was
characterized by rich, connotative language and expressive voice, with ther-
apists focusing on clients’ inner self-exploration. Therapist behavior was then
examined in relation to client outcome. As early as session two, Type 2
therapist behavior, characterized by distorted voice, little connotative lan-
guage, and a focus on client self-observation, predicted poor outcome. In
contrast, Type 3 therapist behavior in the second-to-last session predicted
good client outcome.
Rice’s objective of categorizing clients’ behaviors led to the develop-
ment of the Client Vocal Quality Measure (Rice, Koke, Greenberg, &
Wagstaff, 1979) and the Expressive Stance Measure (Rice, Watson, &
Greenberg, 1993). Client vocal quality was a feature of clients’ style of par-
ticipation that stood out as being most distinguishing of good therapy hours.
Four different types of vocal quality were identified. Externalizing was char-
acterized by the client’s speaking in a rhythmical, chatty way that was
focused on producing an effect on the other. Focused was characterized by
high energy but with broken rhythm and a quality of the client’s attention
being turned inward and focused on inner exploration. Limited was charac-
terized by low-energy, rhythmical speech with a breathless, brittle quality.
Finally, emotional was characterized by clients’ voices breaking up as they
became overwhelmed by emotion (Rice & Kerr, 1986). The Expressive
Stance Measure differentiated the way in which clients engaged with their
experience. This measure consisted of four categories: objective analysis,
labeling subjective reactions, static feeling descriptions, and differentiated
exploration of feeling.
In a study conducted with Wagstaff, Rice observed that clients’ per-
formance in terms of their vocal quality and expressive stance in the sec-
ond session predicted their outcome status at the end of therapy (Rice &
Wagstaff, 1967). External vocal quality and objective analysis differentiated
attrition clients from successful ones, whereas focused voice and a mix of
subjective reaction and objective analysis distinguished the good outcome
clients, and limited vocal quality and objective analysis distinguished the
poor outcome group (Rice & Wagstaff, 1967). The authors suggested that
client vocal quality could help identify which clients might benefit from dif-
ferent approaches to therapy. In a study of client resources, therapist style,
and client process, the client resources, as measured by their Rorschach
scores, were significantly related to client process in the second session,
whereas therapist style of participation was not (Rice & Gaylin, 1973).
However, by the 10th session, both client resources and therapist style of
participation were predictive of client process, which in turn was predic-
tive of outcome (Rice, 1973; 1992).
LAURA RICE 179

Process Research Methods: Task Analysis
Rice developed a method of identifying productive moments in psycho-

therapy and subjecting them to intensive analysis in order to model the
steps necessary to specify resolution and improve client outcomes (Rice &
Greenberg, 1984; Rice & Saperia, 1984). Rice was convinced that different
approaches to psychotherapy fit some clients better than others and that, to
understand the mechanisms of change and improve success rates research, cli-
nicians needed to study productive and unproductive interactions in psycho-
therapy. She criticized an aggregate approach to studying change and
instead advocated a bottom-up approach in which researchers examine
clients’ and therapists’ behaviors and patterns of interaction in specific con-
texts, recognizing that specific behaviors have different meanings in differ-
ent contexts.
Working with clients, Rice (1974; Rice & Saperia, 1984) observed a
specific class of event that she called problematic reaction points, that is,
client statements in which clients queried certain reactions as surprising,
too intense, or otherwise problematic. The statements indicate that clients
are becoming reflective about their own behavior and are potentially ready
to turn inward to explore their experience more systematically. To help
clients explore their reactions and come to a better understanding of their
behavior, Rice developed evocative unfolding, which was an expansion of her
technique of evocative reflections that facilitated clients’ processing of
painful experiences. With evocative unfolding, clients are encouraged to
create vivid, graphic, and idiosyncratic descriptions of the situations in
which problematic reactions occur, so as to identify the triggers for the reac-
tions and to explore them so that clients can better understand their behav-
ior and devise new ways of acting (Rice, 1974; Rice & Saperia, 1984;
Watson & Greenberg, 1996). Subsequently Rice developed a performance
model of the resolution of problematic reaction points and subjected it to
verification (Watson & Rice, 1985; Wiseman & Rice, 1989; Wiseman,
1992). This work was expanded and carried forward by Leslie Greenberg
and his students in their examination of two tasks from gestalt therapy
(Rice & Greenberg, 1984).
Process–Experiential Psychotherapy
The joint program of research on task analysis led to the devel-

opment of process–experiential psychotherapy (PE-EFT), an emotion-
focused therapy for individuals (Greenberg, Rice, & Elliott, 1993; Rice,
1988; Rice & Greenberg, 1992). The authors integrated the client-centered

relationship conditions and marker-guided empathy and focusing with gestalt
interventions to develop a new approach to therapy. PE-EFT advocates that
therapists be attentive to clients’ moment-to-moment process and intervene
differentially at specific client markers indicating that clients were wrestling
with specific cognitive–affective problems such as self-criticisms, problem-
atic reactions, difficulty identifying and labeling feelings, and so on. Today,
PE-EFT is an empirically supported treatment that has numerous advocates
and is taught around the world (Elliott, Watson, Goldman, & Greenberg,
2004; Greenberg & Watson, 2005; Watson, Gordon, Stermac, Steckley, &
Kalogerakos, 2003).
CONCLUSION
Laura Rice made significant contributions to both theory and practice.

She was a therapist of exquisite sensitivity and attunement to her clients’
processes. The privilege of receiving clinical training from Laura on how to
listen to moment-by-moment client process still resonates in us as we hear
her voice on how we can help clients explore their inner experiences and
achieve new self-understanding. As a researcher, Laura’s journey from natu-
ralistic observation led to the development of microtheories of change and
finally an extension of person-centered and experiential psychotherapy with
the development of PE-EFT.
One of her major contributions to the field was her mentorship of a gen-
eration of psychotherapy process researchers that led to a major shift in the
intellectual climate of the Society for Psychotherapy Research (SPR) with
the recognition of the importance of process research. Rice’s mentoring of
Leslie Greenberg, Jeanne Watson, Hadas Wiseman, Catherine Klaasen, Bill
Pinsoff, and other psychotherapy researchers at York University, including
Shake Toukmanian, David Rennie, and Lynne Angus, as well as her support
of researchers at SPR, including Jeremy Safran and Robert Elliott, laid much
of the groundwork for later developments in the field of psychotherapy change
process research. Some innovative developments in different psychotherapy
orientations show Rice’s ongoing influence, including experiential, person-
centered, and emotion-focused approaches (Elliott, et al., 2004; Greenberg &
Watson, 2006), and ruptures in the alliance in relational therapy (Safran &
Muran, 2000) and attachment-based family therapy (Diamond, Diamond,
& Hogue, 2007). These research programs embody Rice’s legacy of the impor-
tance of observation to the construction of models of change and her passion
for the kind of psychotherapy research that would make valid contributions
to practicing clinicians.
LAURA RICE 181

REFERENCES
Butler, J. M., & Rice, L. N. (1963). Audience, self-actualization, and drive theory. In
J. M. Wepman, & R. W. Heine, R. W. (Eds.), Concepts of personality (pp. 79–110).
Hawthorne, NY: Aldine.
Butler, J. M., Rice, L. N., & Wagstaff, A. K. (1963). Quantitative naturalistic research.
Englewood Cliffs, NJ: Prentice-Hall.
Diamond, G. M., Diamond, G. S., & Hogue, A. (2007). Attachment-based family
therapy: Adherence and differentiation. Journal of Marital and Family Therapy,
33, 177–191. doi:10.1111/j.1752–0606.2007.00015.x
Duncan, S., Rice, L. N., & Butler, J. M. (1968). Therapists’ paralanguage in peak
and poor psychotherapy hours. Journal of Abnormal Psychology, 73, 566–570.
doi:10.1037/h0026597
Elliott, R., Watson, J. C., Goldman, R., & Greenberg, L. (2004). Learning emotion
focused psychotherapy: The process-experiential approach to change. Washington,
DC: American Psychological Association. doi:10.1037/10725–000
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The
moment-by-moment process. New York, NY: Guilford.
Greenberg, L. S., & Watson, J. C. (2005). Emotion-focused therapy for depression.
Washington, DC: American Psychological Association. doi:10.1037/11286–000
Rice, L. N. (1965). Therapist’s style of participation and case outcome. Journal of
Consulting Psychology, 29, 155–160. doi:10.1037/h0021926
Rice, L. N. (1973). Client behavior as a function of therapist style and client resources.
Journal of Counseling Psychology, 20, 306–311. doi:10.1037/h0034805
Rice, L. N. (1974). The evocative function of the therapist. In D. A. Wexler & L. N.
Rice (Eds.), Innovations in client-centered therapy (pp. 289–311). New York, NY:
Wiley.
Rice, L. N. (1983). The relationship in client-centered therapy. In M. J. Lambert (Ed.),
Psychotherapy and patient relationships (pp. 36–60). Homewood, IL: Dow Jones Irwin.
Rice, L. N. (1984). Client tasks in client-centered therapy. In R. Levant & J. Shlien
(Eds.), Client-centered therapy and the person-centered approach: New directions in
theory, research and practice (pp.182–202). New York, NY: Praeger.
Rice, L. N. (1988). Integration and the client-centered relationship. Journal of Integra-
tive and Eclectic Psychotherapy, 7, 291–302.
Rice, L. N. (1992). From naturalistic observation of psychotherapy process to micro the-
ories of change. In S. Toukmanian & D. Rennie (Eds.), Psychotherapy process
research: Paradigmatic and narrative approaches (pp. 1–21). Newbury Park, CA: Sage.
Rice, L. N., & Gaylin, N. (1973). Personality processes reflected in client vocal style
and Rorschach performance. Journal of Counseling and Clinical Psychology, 40,
133–138. doi:10.1037/h0034052
Rice, L. N., & Greenberg, L. S. (Eds.). (1984). Patterns of change: Intensive analysis of
psychotherapy process (pp. 29–66). New York, NY: Guilford Press.

Rice, L. N., & Greenberg, L. S. (1991). Two affective change events in client-
centered therapy. In J. Safran & L. Greenberg (Eds.), Emotion, psychotherapy,
and change (pp. 197–226). New York: Guilford Press.
Rice, L. N., & Greenberg, L. S. (1992). Humanistic approaches to psychotherapy. In
D. K. Freedheim, H. J. Freudenberger, J. W. Kessler, S. B. Messer, D. R Peterson,
H. H. Strupp, & P. L Wachtel (Eds.), History of psychotherapy: A century of change
(pp. 197–224). Washington, DC: American Psychological Association.
Rice, L. N., & Kerr, G. P. (1986). Measures of client and therapist vocal quality. In
L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A Research
Handbook (pp. 73–105). New York: Guilford Press.
Rice, L. N., Koke, C. J., Greenberg, L. S., & Wagstaff, A. K. (1979). Manual for the
client vocal quality classification system. Toronto, Canada: York University Coun-
seling and Development Center.
Rice, L. N., & Saperia, E. P. (1984). Task analysis and the resolution of problematic
reactions. In L. N. Rice & L. S. Greenberg (Eds.), Patterns of change: Intensive
analysis of psychotherapy process (pp. 29–66). New York< NY: Guilford Press.
Rice, L. N., & Wagstaff, A. K. (1967). Client vocal quality and expressive styles and
indexes of productive psychotherapy. Journal of Consulting and Clinical Psychol-
ogy, 31, 557<en>563.
Rice, L. N., Watson, J., & Greenberg, L. S. (1993). A measure of clients’ expressive
stance. Toronto, Ontario, Canada: York University.
Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory.
Boston, MA: Houghton-Mifflin.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York, NY: Guilford Press.
Watson, J. C., Gordon, L. B., Stermac, L., Steckley, P., & Kalogerakos, F. (2003).
Comparing the effectiveness of process-experiential with cognitive-behavioral
psychotherapy in the treatment of depression. Journal of Consulting and Clinical
Psychology, 71, 773–781. doi:10.1037/0022–006X.71.4.773
Watson, J. C., & Greenberg, L. S. (1996). Pathways to change in the psychotherapy
of depression: Relating process to session change and outcome. Psychotherapy 33,
262–274. doi:10.1037/0033–3204.33.2.262
Watson, J. C., & Rice, L. N. (1985, June) A test of a model of problematic reaction points.
Paper presented to the Society for Psychotherapy Research, Evanston, IL.
Wiseman, H., & Rice, L. N. (1989). Sequential analyses of therapist-client interac-
tion during change events: A task focused approach. Journal of Consulting and
Clinical Psychology, 57, 281–286. doi:10.1037/0022–006X.57.2.281
Wiseman, H. (1992). Conceptually-based interpersonal process recall (IPR) of change
events: What clients tell us about our microtheory of change. In S. Toukmanian
& D. Rennie (Eds.), Psychotherapy process research: Paradigmatic and narrative
approaches (pp. 51–76). Newbury Park, CA: Sage.
LAURA RICE 183

16
LESLIE GREENBERG:
EMOTIONAL CHANGE LEADS
TO POSITIVE OUTCOME
RHONDA N. GOLDMAN, LYNNE ANGUS, AND JEREMY D. SAFRAN
By implementing innovative research strategies that creatively address

meaningful questions of central concern to researchers and clinicians alike,
Leslie Greenberg has consistently kept the field of psychotherapy research on
its intellectual edge.
MAJOR CONTRIBUTIONS
It is not an overstatement to suggest that over the course of his career

as a psychotherapy researcher, Les Greenberg has significantly influenced
paradigm shifts, particularly with respect to psychotherapy process–outcome
research methodology. As a young academic, he questioned the primary focus
of process–outcome research, suggesting that the key subject of inquiry for
psychotherapy researchers should not be “What treatment for whom?” but
“What intervention at what time for whom?” Not satisfied with simply challeng-
ing psychotherapy researchers to address the complexity of psychotherapy
change processes, he and his mentor, Laura Rice, proceeded to develop and
185
validate a highly innovative events-based research paradigm that was designed
to precisely answer the question he had posed. The events-based approach
introduced a new, rational–empirical method for the intensive analysis of
psychotherapy events—task analysis—that held the promise of providing
greater understanding and specification of productive client performances
and the interventions that facilitate them. Over the next 20 years, events-
based task analyses of specific emotion markers and therapy tasks would
become an important line of research for Greenberg and his collaborators
(Elliott, Watson, Goldman, & Greenberg, 2004; Greenberg & Pinsof, 1986;
Greenberg, Rice, and Elliott, 1993), resulting in the development and refine-
ment of a unique, integrative psychotherapy model.
In a series of publications, Greenberg and graduate student Jeremy
Safran argued that emotional responses, not cognitions or beliefs, prompted
primary evaluations of goal attainment success and signaled the personal sig-
nificance of events for clients, and as such should be the focus of therapeutic
intervention. In Emotion in Psychotherapy (1987), they began to articulate the
principles of working with emotion. With another graduate student, Susan
Johnson, Greenberg suggested that emotion as a primary communication sys-
tem was of major importance for couple therapy (Greenberg & Johnson,
1988). Ultimately, this gave way to the development of two innovative,
research-supported psychotherapy approaches—emotion-focused therapy
(EFT) for individuals and couples. Emotion-focused psychotherapy integrates
gestalt methods into a client-centered relationship and synthesizes emo-
tional, systemic, and constructivist perspectives. Together with collaborators
and authors Laura Rice and Robert Elliott, Greenberg first laid down the guid-
ing principles of the individual approach in the book Facilitating Emotional
Change.
Having articulated a theoretically grounded, integrative model of huma-
nistic psychotherapy, Greenberg and his coauthors now found themselves
challenged by fellow psychotherapy researchers and funding agencies to
empirically demonstrate the efficacy of their new treatment approach to
working with clients. Although psychotherapy process researchers at heart,
he and his colleagues received a major grant in 1992 to compare the effects
of client-centered and process–experiential therapy for depression and ulti-
mately to relate process to both session and final outcome. Over the years,
strong empirical support has also been established for the efficacy of the indi-
vidual EFT approach for depression (Goldman, Greenberg, & Angus, 2006;
Greenberg & Watson, 1998) for resolving unfinished business and promot-
ing forgiveness to help resolve emotional injuries in individuals (Paivio &
Greenberg, 1995) and for the emotion-focused couples approach (Johnson,
Hunsley, Greenberg, &, Schindler, 1999; Goldman & Greenberg, 1992).
186 GOLDMAN, ANGUS, AND SAFRAN

EARLY BEGINNINGS
Leslie Greenberg was born and raised in Johannesburg, South Africa,

and he witnessed the brutal impact of apartheid policies throughout his child-
hood. Sensitized to the negative impact of religious and racial prejudice as a
young man of Jewish heritage, he became actively involved with student
organizations fighting to effect change in the racist policies of the South
African government. His political activism was grounded in humanist values
that held that all human beings—irrespective of religion, race, or gender—
are worthy of respect and compassionate care. Importantly, it was in the
charged political context of the South African apartheid government that
Greenberg would became aware of the abusive impact of unchecked power in
social interactions and the need to assertively challenge those abuses, to effect
positive change. It is these formative experiences in South Africa that pre-
pared Greenbverg, later in life, to take a leadership role in championing
humanistic approaches to therapeutic practice that embrace the values of
mutuality and egalitarianism in therapeutic relationships. Greenberg’s com-
mitment to questioning the received wisdom of dominant cultural norms and
expectations—evidenced in political systems or scientific communities—and
to developing innovative methodological, theoretical, and treatment alter-
natives to address those concerns would mark his evolution as an innovative
psychotherapy researcher and consummate clinical practitioner.
After he finished his undergraduate studies in engineering at the Uni-
versity of Johannesburg, Les and his wife Brenda found themselves at a turn-
ing point. In the face of a growing sense of disillusionment about the possibility
of effecting significant political change in South Africa during their lifetimes,
they made the difficult decision to leave their beloved homeland and emigrate
to Canada—a young country that shared their cherished values of social car-
ing and egalitarianism.
Les Greenberg began a master’s program in systems engineering at
McMaster University in Hamilton, Ontario, in 1968. Toward the end of that
program he first became aware of the work of Laura Rice—a client-centered
therapist and psychotherapy process researcher at York University who was
interested in the role of curiosity in human motivation. As Rice’s research
interests dovetailed with his growing interest in understanding the complex-
ity of knowing human systems, rather than machines, Greenberg made the
fateful decision to meet with Dr. Rice at York. It was the end of the 1960s, a
time of radical social change and redefinition for the culture at large, and so
it would be for him.
Laura Rice decided that she would like to sponsor Greenberg’s admis-
sion to the doctoral program at York. Rice was a client-centered therapist
LESLIE GREENBERG 187

trained by Carl Rogers. Steeped as he was in the existential views of Camus
and Sartre, Greenberg saw that client-centered theory fit with his belief sys-
tem. He also felt critical of behaviorist and psychodynamic authors who
seemed to adopt an overly simplistic view toward the complexity and rich-
ness of human experience. He was much more attracted to the writings of
Carl Rogers and Eugene Gendlin. It was in graduate school that Greenberg
completed a 3-year training at the Gestalt Institute of Toronto with Harvey
Freedman, a protégé of Fritz Perls. He was beginning to lay the groundwork for
his integrative Experiential approach to therapy, although it was not coherent
at the time. Under Rice’s tutelage he completed his ground-breaking dis-
sertation study and, in so doing, introduced an innovative approach to psycho-
therapy process research—events-based task analysis—that would significantly
advance the field of psychotherapy research as a whole.
ACCOMPLISHMENTS
Psychotherapy Process–Outcome Methods
Greenberg’s collaboration with Laura Rice and background in human-

istic therapy, as well as an interest in philosophical views of science that saw
humans as complex, whole systems, contributed to the repudiation of reduc-
tionistic research methods for understanding the complex process of psy-
chotherapy. In their collaborative quest to understand the process of change
in therapy, he and Rice recognized that much of the existing psychotherapy
research assumed that people were similar on some individual difference vari-
able and would react to specific treatments in a somewhat homogenous fash-
ion. The assumption was contrary to their observation and had received little
research confirmation. Greenberg began to focus on process research as a
means to help him further refine his understanding of how therapy works.
Rice and Greenberg (1984) were the first in the field of psychotherapy
research to propose that researchers study groups of episodes or events drawn
from therapy sessions, rather than studying groups of people. They argued that
the criterion for forming samples in psychotherapy process–outcome research
should be an observable process marker that indicates that a client is evidenc-
ing a particular state or problem space, at a specific moment in time. They
also advocated the intensive analysis of contextual, in-session events per-
formed at markers for discovering recurring moments of change.
Around this time he met Juan Pascual-Leone, a neo-Piagetian cognitive
developmental psychologist at York University, who had a broad interest in the
complexity of human development and growth. Pascual-Leone introduced
Greenberg to task analysis—a method that integrates both theory and rigorous

observation of specific in-situation performances, for the identification of heuris-
tic performance models (Pascual-Leone, 1976). Greenberg promoted the imple-
mentation of the method for psychotherapy process research studies to build
models of therapeutic events across therapy sessions, such as, for example, the
two-chair dialogue for intrapsychic conflict, a therapeutic technique adapted
from gestalt therapy. First generating a theoretical model of clients “performing”
the event, researchers could then study multiple two-chair dialogue events across
different therapies, successively comparing the existing theoretical model with
observation, allowing the model to be continually influenced and thus refined.
The final stage involves testing and validating the model, for example, measur-
ing the process during task work and relating it to outcome.
In his dissertation study, published in 1975, Greenberg laid out the prin-
ciples of an events-based approach to psychotherapy process-outcome research.
Patterns of Change (1984), edited with Laura Rice, presented a series of studies
that employed task analysis. The method has been used subsequently to model
many other EFT tasks.
Over the past 20 years, the main focus of Greenberg’s process–outcome
research program has been to further understand the relationship between emo-
tional processes and change in therapy. For instance, Goldman, Greenberg, and
Pos (2005) looked at the relationship between theme-related depth of expe-
riencing and outcome in experiential therapy with depressed clients. Analy-
ses revealed that client level of experiencing (EXP) on core themes in the
last half of therapy was a significant predictor of reduced symptom distress
and increased self-esteem. Experiencing on core themes accounted for out-
come variance over and above that accounted for by early EXP and alliance,
demonstrating that an early emotional processing skill, although likely an
advantage, appears not to be as important as the ability to acquire and/or
increase depth of emotional processing throughout therapy. Studies that
examined expressed arousal showed that a combination of visible emo-
tional arousal and experiencing was a better predictor of outcome than either
index alone, supporting the hypothesis that it is not only arousal of emotion
but also reflection on aroused emotion that produces change (Missirlian,
Toukmanian,Warwar, & Greenberg, 2005). Finally, a recent study showed
that clients with better outcomes expressed significantly more productive,
highly aroused emotions than did clients with poor outcomes, suggesting that
it is productivity, especially of highly aroused emotions, that is important in
facilitating change (Greenberg, Auszra, & Hermann, 2007).
Emotion-Focused Psychotherapy
After completing his PhD in clinical-counseling psychology at York in

1975, Greenberg began his academic career as a young faculty member in the

Department of Counselling at the University of British Columbia. A year ear-
lier, while participating on a panel at the Society for Psychotherapy Research
(SPR), Greenberg had been introduced to Bordin’s model of the working
alliance. He and his new graduate student, Adam Horvath, became intrigued
with the idea of developing a client self-report measure that could capture the
separate contributions of bonds, tasks, and goals for the development of pro-
ductive therapeutic relationships. The Working Alliance Inventory (WAI)—
one of the most widely used alliance measures in the psychotherapy research
field—was the result of this highly productive research collaboration. The
Working Alliance (Horvath & Greenberg, 1994) included seminal contribu-
tions from psychotherapy researchers representing a broad range of therapy
treatment approaches.
Greenberg discovered, in the context of his own psychotherapy process
research program—using the WAI—that task alliance was a stronger predic-
tor of outcome than the bond component or empathy (Horvath & Greenberg,
1989). Although challenging basic assumptions of his client-centered train-
ing at York, this research finding provided Greenberg with empirical support
for his growing sense that client involvement in therapeutic tasks was as
important as empathic engagement, for productive therapeutic outcomes. In
his clinical practice with individuals, he had become increasingly impressed
with how gestalt therapy interventions could rapidly evoke active experienc-
ing in clients. He also felt, however, that the gestalt approach neglected the
importance of empathy and paid insufficient attention to the therapeutic
relationship. Searching for a way to integrate the “active ingredients” of both
approaches, Greenberg began to wonder if the art and skill of therapy might
not involve a balance between “being” and “doing,” or bond and task princi-
ples. Thus began his odyssey to integrate gestalt active interventions with
client-centered relational conditions, a journey that would arrive at an inno-
vative, integrative form of humanistic psychotherapy–EFT.
Serendipitously, around this time Greenberg began a highly generative
collaboration with a young graduate student named Jeremy Safran. Informed
by developments in the newly emerging fields of emotion theory and research,
they set out to develop a systematic theoretical framework that addressed the
contribution of emotion processes for productive therapeutic outcomes. They
took issue with the cognitive therapy proposal that people need to bring
troublesome emotions into line with reason’s dictates. Specifically, they
argued that the arousal and symbolization of primary emotion processes, and
the activation of core emotion schemes and their attendant action tenden-
cies, were the essential ground of new meaning making and sustained client
change and should be the focus of therapeutic interventions. Their articula-
tion of a coherent, theoretical model of client emotional processing in psy-
chotherapy (Greenberg & Safran, 1987) would provide a conceptual

framework for the development of a new, integrative emotion-focused
approach to working with clients and couples.
Greenberg returned to York in 1986 as a full professor of clinical psy-
chology. His career was soaring, and he was receiving increased recognition.
At this time he became more active in SPR, serving as its president in 1989.
Informed by recent developments in his approach to working with emotions
in psychotherapy, Greenberg began actively collaborating with his mentor,
Laura Rice, once again. Rice had become increasingly receptive to Green-
berg’s interest in gestalt methods, and an important collaboration had begun
with Robert Elliott, who was interested in the client’s perspective on the
process of change. The stage was now set for Greenberg and his collaborators
to fully articulate a new, integrative, research-supported treatment approach
that would significantly advance the field of psychotherapy research and prac-
tice. They laid down the principles of their new, brief therapy approach in
Facilitating Emotional Change (1993), which provided a theoretical back-
ground of the approach, articulated relationship and task principles, and pro-
vided step-by-step guides to working with six key markers and tasks in process–
experiential therapy (now more commonly referred to as emotion-focused
therapy). Drawing on a new conceptualization of the contribution of emo-
tion processes for client change, they viewed emotional experience as influ-
encing modes of processing, guiding attention, and enhancing memory and
much behavior in the service of emotional regulation and attachment.
Although at heart a process researcher, Greenberg felt increasingly
challenged to address the question of whether brief humanistic treatments—
especially EFT—could demonstrate treatment efficacy with clinical samples
that had been assessed on standardized treatment outcome measures. He also
began to appreciate that by conducting randomized, controlled treatment tri-
als, he and Rice could have an important impact on the field of psychotherapy
research practice wherein humanistic approaches—such as emotion-focused
and client-centered therapy—would once again be viewed as viable and effi-
cacious. Greenberg also saw the completion of a clinical trial as an excellent
opportunity to intensively investigate client change processes.
In 1992, with Laura Rice as his coinvestigator, Les Greenberg received
a National Institute of Mental Health grant in support of a randomized, con-
trolled trial comparing brief client-centered and brief process–experiential
therapy for depression that proposed to relate key client process variables to
both session and final outcomes. This was also the beginning of an important
collaboration with Jeanne Watson, a student of Laura Rice who came on to
direct the research study. Results showed that both client-centered and
process–experiential therapy were effective treatments for alleviating depres-
sion, although process–experiential therapy was more effective in alleviating
interpersonal problems and increasing self-esteem (Greenberg & Watson,

1998). This finding was based on a sample size of 34 clients (17 in each
group), however, and was moderately powerful according to research criteria
but perhaps not powerful enough to demonstrate differences. He and Lynne
Angus then received a grant in 1998 from the Ontario Mental Health Foun-
dation to conduct a replication study, and they brought on Rhonda Goldman
to direct it. Results demonstrated that with a second sample of 38 clients (19
in each group), EFT (formerly known as process experiential therapy) was
equally effective in alleviating interpersonal problems and increasing self-
esteem but more effective in alleviating depressive symptoms. When the two
samples were combined, providing sufficient power to find differences, EFT
was found to be more effective on all indices of change (Goldman, Greenberg,
& Angus, 2006). Significant differences among treatments were found at ter-
mination on all indices of change, and the differences were maintained at
6-month and 18-month follow-ups (Ellison, Greenberg, Goldman, & Angus,
2009). Given the number of research studies supporting it, EFT for depression
was recently listed by Division 12 (Society of Clinical Psychology) of the
American Psychological Association as an evidence-based treatment.
In addition to demonstrating the effectiveness of EFT for the treatment
of depression, Greenberg and colleagues concurrently conducted research
demonstrating the effectiveness of EFT for treating people with emotional
injuries associated with developmentally significant others from their past
(Paivio & Greenberg, 1995). By establishing substantive empirical support for
the efficacy of client-centered and emotion-focused psychotherapy for depres-
sion, Les and his collaborators have been instrumental in keeping humanistic
approaches in the mainstream of psychotherapy research, training, and practice.
In the past decade, Greenberg continued to develop and differentiate
his theory of emotion in psychotherapy, publishing a book explicating how
to work with emotions (Greenberg & Paivio, 1997), another titled Emotion-
Focused Therapy (Greenberg, 2002), in which he described the main job of
the therapist as being one of coaching people to become more emotionally
intelligent, and yet another in 2007 (Greenberg & Watson), in which he
spelled out the emotion-focused approach to depression. From an emotion-
focused perspective, disorder is seen as resulting from failures in the dyadic
regulation of affect, avoidance of affect, traumatic learning, and lack of
processing of emotion. Awareness, regulation, and transformation through
accessing an alternate emotion are offered as three empirically supported
principles of emotional change.
Emotion-Focused Therapy for Couples
Upon returning from a sabbatical in 1980 at the Mental Research Insti-

tute in Palo Alto, California, where he learned about the psychotherapeutic

treatment of couples and families, Greenberg was surprised at how impressed
he was with the importance of power dynamics in relationships (given his polit-
ical experiences in South Africa). Feeling also, however, that an effective ther-
apeutic approach for couples needed to emphasize a strong relationship and a
focus on underlying emotions, he and his graduate student Susan Johnson
began to develop an approach to couples therapy that integrated systemic and
experiential approaches. The result was an EFT approach for couples (EFT-C;
Greenberg & Johnson, 1988). His interest in studying couples had evolved
mainly from his research on resolving intrapsychic conflict, in which he found
that softening of the critic led to resolution. The EFT-C process looked very
much like interpersonal conflict resolution, in which a critical or blaming part-
ner softens and a withdrawn partner reveals. It was for the purpose of studying
how couples resolved conflict that the couple therapy manual and Greenberg’s
first outcome study were first developed. As we have said, at heart he was always
a process researcher. After its initial development, Greenberg moved away from
the promotion of EFT-C to concentrate on research on individual therapy,
making room for Johnson to integrate attachment theory (Johnson & Whiffen,
2003) and successfully promote its development. Over the years strong empir-
ical support has been established for the efficacy of EFT-C in reducing couples’
distress (Johnson, Hunsley, Greenberg, & Schindler, 1999). Greenberg became
more involved again in research on EFT-C only after he had developed a study
of the process of forgiveness in both individuals and couples. Research evalu-
ated the effects of EFT-C for couples when one member had an unresolved
emotional injury resulting from the partner’s actions (Greenberg, Warwar, &
Malcolm, 2003) and demonstrated that couples scored significantly better than
waiting-list controls on all indices of change.
Thus began the resurgence of his effort to develop EFT-C and investi-
gate it further. In Emotion-Focused Couples Therapy: The Dynamics of Emotion,
Love, and Power, Greenberg and Goldman (2008) further delineated the
approach to couples that he originally inspired. The book expands the frame-
work of the therapy, focusing more intently on the role of emotion in mari-
tal therapy and the importance of both self and system change through the
promotion of both self-soothing and other-soothing. The book outlines
explicitly how to work with anger, sadness, fear, and shame, as well as with
positive emotions, and focuses on both the dominance dimension of couples
interactions as well as the attachment dimension.
Les Greenberg has significantly influenced the field of psychotherapy
research, beginning with the events-based paradigm that shifted the empha-
sis of psychotherapy research to a focus on the process and context of psycho-
therapy to understand how change occurs. While he may not have set out to
create a new approach to psychotherapy, continued research efforts designed
to articulate how therapy works eventually led to the development of an

integrative approach that marries client-centered therapy and gestalt meth-
ods and integrates modern emotion theory to create EFT. This was further
adapted for couples with an integration of systemic, interactional therapy the-
ory. Research efforts have resulted in the establishment of empirical support
for these therapies and further articulation of how emotional change leads to
positive outcome in psychotherapy.
REFERENCES
Ellison, J. A., Greenberg, L. S., Goldman, R., & Angus, L. (2009). Maintenance of
gains following experiential therapies for depression. Journal of Consulting and
Clinical Psychology, 77(1), 103–112. doi:10.1037/a0014653
Elliott, R., Watson, J., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-
focused therapy: The process-experiential approach to change. Washington, DC:
American Psychological Assocation. doi:10.1037/10725-000
Goldman, A., & Greenberg, L. (1992). Comparison of an integrated systemic and
emotionally focused approach to couples therapy. Journal of Consulting and Clin-
ical Psychology, 60, 962–969.
Goldman, R. N., Greenberg, L. S., & Angus, L. A. (2006). The effects of adding
emotion-focused interventions to the client-centered relationship conditions in
the treatment of depression. Psychotherapy Research, 16, 536–546. doi:10.1080/
10503300600589456
Goldman, R., Greenberg, L., & Pos, A. (2005). Depth of emotional experience and out-
come. Psychotherapy Research, 15, 248–260. doi:10.1080/10503300512331385188
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their
feelings. Washington, DC: American Psychological Assocation. doi:10.1037/
10447-000
Greenberg, L. S., Auszra, L., & Hermann, I. R. (2007). The relationship among emo-
tional productivity, emotional arousal and outcome in experiential therapy of
depression. Psychotherapy Research, 17, 482–493. doi:10.1080/10503300600977800
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-focused couples therapy: the
dynamics of emotion, love, and power. Washington, DC: American Psychological
Assocation. doi:10.1037/11750-000
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples.
Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy. New
York, NY: Guilford Press.
Greenberg, L. S., & Pinsof, W. M. (1986). The psychotherapeutic process: A research
handbook. New York, NY: Guilford Press.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The
moment by moment process. New York, NY: Guilford Press.

Greenberg, L. S., & Safran, J. (1987). Emotion in Psychotherapy. New York, NY:
Guilford.
Greenberg, L. S. Warwar, S., & Malcolm, W. (2003, June). The differential effects
of emotion-focused therapy and psychoeducation, for the treatment of emo-
tional injury: Letting go and forgiving. Paper presented for panel at a meeting
of the Society for Psychotherapy Research, Weimar, Germany
Greenberg, L. S., & Watson, J. (1998). Experiential therapy of depression: Differen-
tial effects of client-centered relationship conditions and process experiential
interventions. Psychotherapy Research, 8, 210–224. doi:10.1093/ptr/8.2.210
Horvath, A., & Greenberg, L. S. (1989). Development and validation of the Work-
ing Alliance Inventory. Journal of Counseling Psychology, 36, 223–233.
Horvath, A., & Greenberg, L. S. (Eds.). (1994). The working alliance: Theory, research,
and practice. New York, NY: Wiley.
Johnson, S. M., Hunsley, J., Greenberg, G., & Schindler, D. (1999). Emotionally
focused couples therapy: Status and challenges. Clinical Psychology: Science and
Practice, 6(1), 67–69. doi:10.1093/clipsy/6.1.67
Johnson, S., & Whiffen, V. (Eds.). (2003). Attachment theory: A perspective for
couple and family therapy. New York, NY: Guilford Press.
Missirlian, T. M., Toukmanian, S., Warwar, S., & Greenberg, L. (2005). Emotional
arousal, client perceptual processing, and the working alliance in experiential
psychotherapy for depression. Journal of Consulting and Clinical Psychology, 73,
861–871. doi:10.1037/0022-006X.73.5.861
Pascual-Leone, J. (1976). Metasubjective problems of constructive cognition: Forms
of knowing and their psychological mechanisms. Canadian Psychological Review,
17, 110–125. doi:10.1037/h0081828
Paivio, S., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of
experiential therapy using the empty-chair dialogue. Journal of Consulting and
Clinical Psychology, 63, 419–425.
Rice, L. N., & Greenberg, L. S. (Eds). (1984). Patterns of change: Intensive analysis of
psychotherapy Practice. New York, NY: Guilford Press.

C. RELATIONSHIP
VARIABLES
17
EDWARD S. BORDIN: INNOVATIVE
THINKER, INFLUENTIAL
INVESTIGATOR,
AND INSPIRING TEACHER
MICHAEL J. CONSTANTINO, NICHOLAS LADANY,
AND THOMAS D. BORKOVEC
Those who knew Ed Bordin personally were touched by his humanity,

integrity, and intellectual brilliance. Those who knew him only through
his professional writing were touched in a similar fashion, a feat not easily
attained. As authors of this chapter, we all have felt the ease and effortless-
ness that comes from reading and rereading Bordin’s work. Moreover, whether
through direct or indirect experience with Bordin, we all have been inspired
by his vision and foresight, impressive scholarship, respect for others’ ideas, and
integrative spirit.
Irene Elkin (1993) noted in her Society for Psychotherapy Research
(SPR) tribute to Bordin that he was “one of the most important figures in
psychotherapy research, who made some of the most important contributions
to our field.” In fact, Bordin had a remarkable breadth of professional interests
about which he wrote and studied. By his own account, Bordin (1987) had two
“enduring preoccupations.” The first focused on vocational choice and personal
development, whereas the second focused on personal change process and a
theory of working alliance as the cornerstone of counseling and psychotherapy.
However, our informal “factor analysis” of Bordin’s published work also
revealed at least seven other broad and multifaceted factors: (a) dimensions
of the psychotherapy and counseling process (including client, therapist, and
199
relational factors); (b) psychotherapy integration; (c) psychometrics (as
related to the measurement of such constructs as ambiguity, depth of inter-
pretation, resistance, and client compliance with free association); (d) psycho-
therapy research and design (including laboratory and effectiveness studies);
(e) statistical issues; (f) diagnosis; and (g) supervision. As a psychotherapy
researcher, Bordin argued for situating the science of psychotherapy within
a larger context of human behavior, thus championing the integration of
basic and applied knowledge. And as an exemplary scientist–practitioner,
Bordin also understood the inherent tensions in clinical and research moti-
vations and agendas, as he eloquently discussed in his article “Curiosity,
Compassion, and Doubt: The Dilemma of the Psychologist” (Bordin, 1966).
With his keen understanding of this dilemma, devotion to both sides of
this false dichotomy, and his genuine synthesizing character, Bordin’s
career personified the marriage of science and practice. In the remainder
of this essay, we elaborate on Bordin’s personal life and professional con-
tributions, with particular attention to his pioneering working alliance
theory.
EARLY BEGINNINGS
Edward Bordin was born in Pennsylvania on November 7, 1913, to

Russian Jewish immigrant parents. He was the youngest of three boys. Bordin
(1987) characterized his father as reflective and analytical and his mother as
driven. Based on their influences and his birth order, he described himself as
an outsider with a questioning attitude, an “analytical, oppositional charac-
ter” (1987, p. 359). To us, this self-concept seems synonymous with our reflec-
tions of Bordin as a constructively critical, innovative, and forward thinker.
Equipped with his analytical disposition, Bordin earned his bachelor’s and
master’s degrees at Temple University. He earned his doctorate in 1942 at
Ohio State, where he overlapped for several years with Carl Rogers, who was
a professor at Ohio State from 1940 to 1945, and engaged in substantial intel-
lectual discourse with J. R. Kantor, to whom he acknowledged owing an intel-
lectual debt (Bordin, 1987). After 3 years in the armed forces, Bordin took
his first academic positions at the University of Minnesota and then Wash-
ington State University. In 1948, he was hired at the University of Michigan
as an associate professor of psychology and the director of the Counseling
Division of the Bureau of Psychological Services (Galinsky, 1995). Bordin
was promoted to full professor in 1955. During his long tenure at Michigan,
Bordin made significant theoretical and empirical contributions, as well as
significantly influencing students he taught and mentored. Galinsky (1995)
described Bordin as
200 CONSTANTINO, LADANY, AND BORKOVEC

a first-rate teacher not only because of his own enthusiasm for new ideas
and his wish to stretch students’ capacity to think about complex issues
but also because of the richness and breadth of his knowledge, which
spanned many areas of psychology. (p. 172)
Edward Bordin, with his low-key and respectful, yet dynamic and influ-
ential personality, died in La Jolla, California, on August 24, 1992.
MAJOR CONTRIBUTIONS
Bordin (1987), during his 1986 Leona Tyler Award Address (an honor
bestowed on him by the Division of Counseling Psychology of the American
Psychological Association [APA]), humbly described having two enduring
preoccupations. However, one could view his early career focus on vocational
decision-making and his later career focus on his working alliance theory as
the end points on a continuum of influence tied together by related and recip-
rocal contributions in counseling and psychotherapy integration, process, and
research. We use these categories as organizational heuristics in recounting
Bordin’s major contributions.
Vocational Decision-Making
Dissatisfied with and critical of the dominant psychological testing

tradition, an attitude he shared with Carl Rogers (see Orlinsky & Rønnestad,
2000), Bordin became interested in his early career in moving beyond test
scores to understanding personal context as a determinant of vocational
choice and satisfaction. Drawing on psychoanalytic constructs such as
resistance, repression, and conflict, as well as Eriksonian (1959) constructs
such as self-identity, Bordin strived to broaden the field’s understanding of
the vocational choice process and its related anxieties, expectations, and
behaviors by understanding the client personally, developmentally, and
dynamically. In this vein, and consistent with Rogers (1942, 1951), Bordin
rejected narrow rationalism and the counselor-as-expert perspective, instead
promoting a dynamically based interpersonal model first applied to voca-
tional counseling and later broadened to the counseling process in general
(which he defined as almost any human condition inviting intervention
by another; e.g., Bordin, 1948, 1955, 1980a). In his 1986 Leona Tyler Award
Address, Bordin acknowledged that his early focus on personal develop-
ment and personality as factors in vocational decision making generated
his later working alliance theory. In particular, he likened the importance
of realistic and compatible expectations for vocational counseling (e.g., a
client understanding that such counseling is not simply a matter of having
EDWARD S. BORDIN 201

test results interpreted back to her or him) to the psychotherapy process (e.g.,
a client understanding that an expert therapist will not simply prescribe a uni-
form road map to recovery). However, before fully elaborating his alliance
theory, Bordin’s academic trajectory turned next to the notions of integra-
tion and process, both conceptually and empirically.
Counseling and Psychotherapy Integration, Process, and Research
Although Bordin agreed with Rogers’s denunciation of rationalism

and counselor-as-expert perspective and the latter’s promotion of the ther-
apeutic relationship, he also respectfully took issue with Rogers’s dogmatic
view of what separated directive from nondirective in therapeutic approach
(Orlinsky & Rønnestad, 2000). As Bordin (1987) recounted, when he was
at the University of Minnesota he was lumped by Rogerians into the direc-
tive camp. However, his same philosophies were viewed as nondirective by
the psychoanalytic thinkers at the University of Michigan. Bordin dis-
cussed how it was through this tension, and his “analytical oppositional”
character, that he began exploring in depth the values, virtues, and short-
comings of both the directive and nondirective camps and the psycho-
analytic and client-centered philosophies. In the aforementioned 1986
address, he noted:
I was saved from a chameleonlike eclecticism and led toward true inte-
gration. I assumed that each of the proponents was seeing and expressing
an important point of view. I thought that each was concentrating on dif-
ferent aspects of persons as well as on different kinds of persons with dif-
ferent pathological states. Rather than choosing one approach, I selected
aspects of how they helped another and developed understandings of how
the situation and the disposition of the person being helped influenced
response. (Bordin, 1987, p. 362)
It was perhaps at this stage of his career that Bordin’s name started to
become, from our perspective, synonymous with the notions of synthesis and
integration within the counseling and psychotherapy fields. In fact, it was his
integrationist thinking that led him to collaborate at Michigan with such col-
leagues as Harold Raush and Allen Dittman in examining the active ingredi-
ents of psychotherapeutic change. This quest for uncovering what makes
psychotherapy work began with the careful development of psychometrically
sound measures of ambiguity, depth of interpretation, client resistance, and
client compliance with free association (all constructs that underscore his
psychoanalytic background).

Through his focus on specific psychotherapeutic processes, Bordin was
calling for a paradigm shift in treatment research that focused on the dis-
mantling of treatment packages to isolate causative change factors, with such
work guided by theories that cut across articulated treatment packages. In this
call, one can see Bordin’s responsiveness to and immense influence on the field
of psychotherapy research, including ideas that have subsequently persisted and
matured, such as the scientific value of component control designs (e.g., Behar
& Borkovec, 2003) and the clinical and empirical value of uncovering and rig-
orously studying common treatment and change principles (e.g., Castonguay
& Beutler, 2006). Bordin impressively attempted to reconcile the tension
between proponents of the so-called common, or nonspecific, factors and pro-
ponents of theory-specific factors. He argued that although all therapies have
in common the importance of a quality working alliance, they also possess
diverse tasks or task sets. He advocated the use of both the clinical laboratory
and the naturalistic clinical setting to isolate and test the influence of specific
tasks on various kinds of clients. Again we see in Bordin’s ideas the importance
of understanding the influence of personal context and development on coun-
seling and psychotherapy interventions. We also see a genuine attempt to
integrate at all levels of analysis both science and practice, basic and applied.
In her SPR tribute, Elkin (1993) noted that Bordin perhaps made the strongest
and most elegant case for such integration and the necessary reciprocal influ-
ence between the lab and clinic. And in doing so, he also cautioned researchers
against “oversimplification” in the lab and the danger of neglecting naturalis-
tic phenomena related to the construct under study (Bordin, 1965).
To us, such forward thinking could be viewed as a precursor to impor-
tant contemporary developments, such as the bringing together of scientists
and practitioners to preserve the interests of both parties and to advance clin-
ical knowledge through collaboration (see, e.g., Borkovec, Echemendia,
Ragusea, & Ruiz, 2001), a prediction that Bordin made in his article “Coun-
seling Psychology in the Year 2000: Prophecy of Wish Fulfillment?” (Bordin,
1980b). In fact, as Elkin noted in her tribute, Bordin remarkably anticipated
many developments in three domains: clinical (e.g., the need for developing
a foundational alliance with schizoid and borderline clients), statistical
(e.g., the need for a reliable statistic that would take base rates into account),
and research (e.g., the need for developing coding schemes to capture inter-
personal process and to account for individual bias of coders within rating sys-
tems). Many such issues were addressed in his “masterful research blueprint”
(Galinsky, 1995, p. 172), Research Strategies in Psychotherapy (Bordin, 1974).
The timelessness of this celebrated contribution was underscored in its recent
endorsement by several contributors to an SPR Web discussion list on clas-
sic psychotherapy process research references.

Working Alliance Theory
In articulating his thoughts on a new tack in psychotherapy theory and

research, Bordin was convinced that it would be based in the working alliance
construct (Bordin, 1987). Always interested in how dimensions of the coun-
seling process interact with the personal attributes of the person seeking a cer-
tain type of help and change, Bordin refocused the field on the client–
therapist relationship. Before his seminal working alliance addresses (Bordin,
1976, 1980c) and article (Bordin, 1979), research interest in the relationship
construct had started to wane, likely as a function of inconsistent findings
related to Rogers’s (1957) necessary and sufficient conditions hypothesis.
Although lauding Rogers’s relationship focus, Bordin drew on his own psy-
choanalytic background to propose a novel conceptualization of the alliance
that focused on the perpetual negotiation of therapeutic goals and tasks
between client and therapist as a function of client and therapist character-
istics and the related strain of the work. As he noted in his 1986 address:
I do not find it credible that change goals are interchangeable and that
all of the therapeutic tasks that are embedded in various treatment pack-
ages are alternate paths to the same goal. It seems more likely to me that
each of many sensitive and creative therapists arrived at methods that
were appropriate to the kinds of persons he or she was trying to help who
were different from the persons who were being helped by another
equally sensitive therapist. (Bordin, 1987, p. 363)
Clearly privileging integration in theory and practice, as well as the per-

son of the client and therapist, Bordin (1979, 1980c) viewed the working
alliance as differing in strength and kind. He was central in formulating the
alliance as not only scaffolding for subsequent change but also as a change
product in and of itself via a process of building and repairing alliance breaks.
To Bordin, a central component in such relational negotiation stemmed from
understanding individual differences in clients’ differential abilities to work
through different therapeutic tasks, depending on the specific problems for
which they sought change. Embedded in the building and negotiating of
working alliances, he argued, is a therapeutic opportunity to tap into and then
disrupt self-defeating patterns of the client. As Bordin (1980c) discussed in
his SPR presidential address, such working through with the therapist will allow
the person to develop new ways of thinking, feeling, or acting with self and
others, a process akin to an interpersonal corrective experience complementary
to theories set forth by the two other influential theorists in this section of the
volume, Donald Kiesler and Lorna Benjamin.
In his discussion of different types of alliances, Bordin (1979, 1980c)
also made a distinction between bonds that reflect, to borrow Benjamin’s

(2003) term, regressive loyalty to the past versus those that reflect, again to bor-
row Benjamin’s term, growth collaboration. Bordin also differentiated bonds
that result from collaboration versus those that contribute to collaboration.
To Bordin, it was this latter type that was so central to therapeutic change.
With his clear articulation that the alliance can be both a by-product of col-
laborative success and a mechanism of subsequent change, Bordin in many
ways anticipated the subsequent standing debate on this issue, and his view
may perhaps still hold the most promise for reconciling these disparate view-
points and for explaining inconsistent findings related to alliance–outcome
associations when controlling for prior change (see, e.g., Barber, 2009). To
Bordin’s way of thinking, whether the alliance is a by-product of improve-
ment or a facilitator of it depends on the alliance being measured and who is
engaging in the relationship.
As a pathway to understanding change from different perspectives
under different conditions with different clients, Bordin’s (1980c, 1979, 1994)
alliance theory did nothing less than rejuvenate the field of psychotherapy
process research (Elkin, 1993). His conceptualization of the alliance, which
was more easily testable than previous relationship constructs (Orlinsky &
Rønnestad, 2000), was the primary impetus for alliance-focused instrument
development (Horvath & Greenberg, 1989) and what has now been several
decades of rigorous and voluminous alliance research (see Horvath & Bedi,
2002; Castonguay, Constantino, & Grosse Holtforth, 2006). Furthermore,
Bordin was not content with simply measuring the resultant strength of the
working alliance and linking that with outcome. He was keenly interested in
how strong alliances are developed and change over time, an agenda that has
been taken up in a second generation of alliance research (Safran, Muran,
Samstag, & Stevens, 2002). Bordin himself focused on the importance of
client–therapist mutuality with regard to therapy goals and tasks based on the
person of the client and her or his personal paradigm for understanding
pathology and change. Bordin stressed that there will be differences in the
types of goals and tasks that will lend themselves to certain clients, based on
a complex combination of personal characteristics, diagnosis, and context.
Following this tradition, the second wave of alliance research has illuminated
several client characteristics that may help forecast the development of a
quality working alliance, such as expectations for improvement and inter-
personal problems (e.g., Constantino, Arnow, Blasey, & Agras, 2005). Bordin
also posited the importance of making mutuality transparent, that is, translat-
ing change language in a way that fits a client’s own paradigm of problem,
process, and change.
As perhaps one of the most significant barometers of the influence of
a theory, Bordin’s (1979, 1994) working alliance theory has not only been
widely cited in relation to individual psychotherapy, but has also been

adapted for contexts outside of its original scope, such as family therapy (e.g.,
Johnson & Wright, 2002). Moreover, his model of the supervisory work
alliance (Bordin, 1983) has been the most investigated variable in psycho-
therapy supervision and, similar to findings for the therapeutic working
alliance, the supervisory working alliance has been recognized as the founda-
tion upon which both effective and ineffective supervision are based (Ladany
& Inman, in press).
OTHER ACCOMPLISHMENTS
Bordin had many accomplishments in his academic career. Among

the most notable, he served as president of APA’s Division of Counseling
Psychology in 1955, as well as chair of its Education and Training Board in
1956 and as a member of its Board of Professional Affairs in 1964. As noted,
he won the division’s Leona Tyler Career Contribution Award in 1986. He
was also president of SPR in 1979–1980 and awarded the SPR Senior Career
Research Award in 1985. In recognition of his immense and lasting influ-
ence on SPR, the society also established an annual student travel award in
his name. Bordin was the editor of the Journal of Consulting Psychology from
1959 to 1964, and he was an integral participant in the National Institute of
Mental Health Outcome Measures Project, to which Elkin (1993) recalled
his contributions as “profound.” Finally, Bordin is credited with shaping the
Counseling Center at the University of Michigan into a highly successful
training, research, and student services center (Galinsky, 1995), where he
seemed to be on the cutting edge with respect to more recently articulated
calls for conducting research in training clinics (e.g., Borkovec, 2004).
CONCLUSION
As should be clear, we agree with Elkin that Bordin was one of the
most important and influential figures in the fields of counseling and psycho-
therapy. He was an innovative thinker who used his creative, integrative,
and pioneering character and spirit to both define (when the field of voca-
tional counseling required new definitions) and to rejuvenate (when the
field of psychotherapy required rejuvenation of the relationship construct).
All the while, Bordin was a masterful scientist, inspirational mentor, and
strong leader. As a testament to his influence, we offer the threefold lesson
that Ed Bordin taught T. D. Borkovec during a dinner one evening—a les-
son that we believe can prove inspirational to anyone who aspires to be a
psychotherapy researcher:

1. It does not matter what we choose as a research topic or a the-
oretical perspective, as long as we go deeply into what we have
chosen and do so with intrinsic devotion to the truth and its
discovery.
2. The reason that the choice does not matter, as long as the quest
is deep and honorable, is that everything is connected to every-
thing else.
3. Differing theories contain differing relative truths at their specific
level, but are the same at their metaphorical level, and it is at
this level that we can best approximate (though never achieve)
absolute truth.
REFERENCES
Barber, J. P. (2009). Toward a working through of some core conflicts in psychother-

apy research. Psychotherapy Research, 19, 1–12. doi:10.1080/10503300802609680
Behar, E. S., & Borkovec, T. D. (2003). Psychotherapy outcome research. In
J. A. Schinka & W. F. Velicer (Eds.), Handbook of psychology: Research methods
in psychology (Vol. 2, pp. 213–240). New York, NY: Wiley.
Benjamin, L. S. (2003). Interpersonal reconstructive therapy: Promoting change in non-
sponders. New York, NY: Guilford Press.
Bordin, E. S. (1948). Dimensions of the counseling process. Journal of Clin-
ical Psychology, 4, 240–244. doi:10.1002/1097-4679(194807)4:3<240::AID-
JCLP2270040306>3.0.CO;2-1
Bordin, E. S. (1955). Psychological counseling. East Norwalk, CT: Appleton-Century-
Crofts. doi:10.1037/10642-000
Bordin, E. S. (1965). Simplification as a strategy for research in psychotherapy. Jour-
nal of Consulting Psychology, 29, 493–503. doi:10.1037/h0022760
Bordin, E. S. (1966). Curiosity, compassion, and doubt: The dilemma of the psychol-
ogist. American Psychologist, 21, 116–121. doi:10.1037/h0023187
Bordin, E. S. (1974). Research strategies in psychotherapy. New York, NY: Wiley.
Bordin, E. S. (1976, September). The working alliance: Basis for a general theory of
psychotherapy. Paper presented at the 1976 American Psychological Association
Convention, Washington, DC.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the
working alliance. Psychotherapy, 16, 252–260. doi:10.1037/h0085885
Bordin, E. S. (1980a). A psychodynamic view of counseling psychology. Counseling
Psychologist, 9, 62–70. doi:10.1177/001100008000900114
Bordin, E. S. (1980b). Counseling psychology in the year 2000: Prophecy of wish fulfill-
ment? Counseling Psychologist, 8, 24–26. doi:10.1177/001100008000800410

Bordin, E. S. (1980c, June). Of human bonds that bind or free. Presidential address
given at the 11th annual meeting of the Society for Psychotherapy Research,
Pacific Grove, CA.
Bordin, E. S. (1983). Supervision in counseling: II. Contemporary models of super-
vision: A working alliance based model of supervision. Counseling Psychologist,
11, 35–42. doi:10.1177/0011000083111007
Bordin, E. S. (1987). 1986 Leona Tyler Address: Aim and trajectory. Counseling Psy-
chologist, 15, 358–367. doi:10.1177/0011000087152018
Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New
directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance:
Theory, research and practice (pp. 13–37). New York, NY: Wiley.
Borkovec, T. D., Echemendia, R. J., Ragusea, S. A., & Ruiz, M. (2001). The Penn-
sylvania Practice Research Network and future possibilities for clinically mean-
ingful and scientifically rigorous psychotherapy effectiveness research. Clinical
Psychology: Science and Practice, 8, 155–167. doi:10.1093/clipsy/8.2.155
Borkovec, T. D. (2004). Research in training clinics and practice research networks:
A route to the integration of science and practice. Clinical Psychology: Science
and Practice, 11, 211–215. doi:10.1093/clipsy/bph073
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that
work. New York, NY: Oxford University Press.
Castonguay, L. G., Constantino, M. J., & Grosse Holtforth, M. (2006). The working
alliance: Where are we and where should we go? Psychotherapy, 43, 271–279.
doi:10.1037/0033-3204.43.3.271
Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association
between patient characteristics and the therapeutic alliance in cognitive–
behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting
and Clinical Psychology, 73, 203–211. doi:10.1037/0022-006X.73.2.203
Elkin, I. (1993, June). Tribute to Ed Bordin. Paper presented at the 24th annual meeting
of the Society for Psychotherapy Research, Pittsburgh, PA.
Erikson, E. H. (1959). Identity and the life cycle. Oxford, England: International
Universities Press.
Galinsky, M. (1995). Edward S. Bordin (1913–1992): Obituary. American Psychologist,
50, 172. doi:10.1037/0003-066X.50.3.172
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psycho-
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the
Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233.
doi:10.1037/0022-0167.36.2.223
Johnson, L. N., & Wright, D. W. (2002). Revisiting Bordin’s theory on the thera-
peutic alliance: Implications for family therapy. Contemporary Family Therapy,
24, 257–269. doi:10.1023/A:1015395223978

Ladany, N., & Inman, A. G. (in press). Training and supervision. In E. A. Altmaier
& J. I. Hansen (Eds.), Oxford handbook of counseling psychology. New York, NY:
Oxford University Press.
Orlinsky, D. E., & Rønnestad, M. H. (2000). Ironies in the history of psycho-
therapy research: Rogers, Bordin, and the shape of things that came. Journal of
Clinical Psychology, 56, 841–851. doi:10.1002/1097-4679(200007)56:7<841::
AID-JCLP3>3.0.CO;2-V
Rogers, C. R. (1942). Counseling and psychotherapy: New concepts in practice. Boston,
MA: Houghton Mifflin.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personal-
ity change. Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance
ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapists
contributions and responsiveness to patients (pp. 235–254). New York, NY: Oxford
University Press.

18
DONALD J. KIESLER:
INTERPERSONAL MANIFESTO
CHRISTOPHER C. WAGNER AND JEREMY D. SAFRAN
Donald J. Kiesler (1933–2007) was a clinical psychologist who focused on

a variety of issues related to personality, psychopathology, and psychotherapy
over a 45-year career. Although his direct empirical contributions to psychother-
apy research left an important legacy in and of themselves, we believe that his
conceptual, theoretical, and analytical contributions to the field were even more
significant. In the 1960s, he identified several common myths that he believed
were keeping the field of psychotherapy research from fulfilling its promise, and
he developed a paradigm that helped move the field beyond the question, “Does
psychotherapy work?” and on to the significantly more useful question, “What
works, for whom?” Thus began the era of factorial psychotherapy outcomes
research, which in many respects continues to define the structure of outcomes
research today. Kiesler also furthered work in psychotherapy process research
as research director of Carl Rogers’s Wisconsin study of psychotherapy with
schizophrenia patients, codeveloping some of the first process measurement
instruments and later publishing an encyclopedic book cataloguing method-
ologies of psychotherapy process research. During the 1970s, he focused on non-
verbal communication in dyadic relationships, leading him to his later focus on
interpersonal theory and research and the development of his interpersonal
communications psychotherapy model. His emeritus years found him focusing
211
on biopsychosocial models of mental disorders and studying the role of health
care interactions in medical patient outcomes.
EARLY BEGINNINGS
Donald Kiesler was raised in Louisville, Kentucky, the second of four

boys in a German family. He attended parochial schools and a Catholic high
school, played on school football and basketball teams through high school,
and participated on his high school debate team. He attended a Catholic novi-
tiate in Indiana, studying to become a priest, before deciding instead that he
wanted to pursue a career as a high school counselor. During his pursuit of that
goal, he was offered a job in a psychology department. Believing that this had
better career potential, he chose psychology as his field. In later years he would
laugh about how casual career entry was in those “innocent” days, when word
of mouth from one professional to another could result in a telephone call
offering one a job, and thus the beginning of a lifelong career.
He pursued his PhD at the University of Illinois, obtaining it in 1963.
Like many in his field in that era, he was trained in psychodynamic therapy
on the one hand and experimental research methods on the other, and he
grew frustrated that the two were separate streams flowing through his profes-
sional life, parallel but ever disconnected. This early frustration provided the
impetus for the following 45 years of work focused on integrating theory,
Rogers’s Wisconsin Psychotherapy Project
Shortly after completing his graduate education, Kiesler landed a prom-

ising opportunity as a postdoctoral researcher with Carl Rogers, on Rogers’s
innovative Wisconsin-based research project studying the effectiveness of
client-centered therapy for individuals with schizophrenia. His excitement was
to be short-lived, however, because within 3 weeks of his arrival in Madison,
serious problems emerged with the project. This was the first major psycho-
therapy process research study of its kind, and all therapy sessions were
recorded and the recordings coded by a team of researchers. One day, however,
it was discovered that most of the coded data from the project had disappeared.
Suspicion fell on a team member, based on circumstantial evidence, and
4 years of significant turmoil followed for all involved. As the new research
director on the project, Kiesler led the effort to recode the recordings over the
212 WAGNER AND SAFRAN

next year, but he was caught up (and actively participated) in a struggle of
considerable proportions among team members, eventually escalating to hos-
tile interactions, threats of lawsuits over authorship credit, and the ending
of several professional relationships.
Kiesler believed that Rogers did not adequately address the apparent theft
of data and that Rogers’s nondirective leadership style exacerbated the prob-
lems among team members (D. Kiesler, personal communication, August 6,
1993). Kiesler came to feel that Rogers sacrificed congruence in favor of
unconditional positive regard, both as a therapist and in communication with
his research team. Eventually, the book summarizing the multiyear project
appeared (Rogers, Gendlin, Kiesler, & Truax, 1967), but after years of antic-
ipation, the mixed findings were received with relatively little enthusiasm by
the field. This difficult period in Kiesler’s personal and professional life played
a role in his subsequent development of an interest in the role that incongru-
ent communication plays in interpersonal problems and an interest in the use
of therapeutic metacommunication as a vehicle for highlighting this type of
incongruence in treatment and communicating congruently as a therapist.
Conceptual and Methodological Contributions

to Psychotherapy Research
As the Wisconsin project wound down, Kiesler turned to the broad

methodological question of how to move psychotherapy research in a more
sophisticated direction that might yield results that could challenge Eysenck’s
(1952) highly publicized conclusion that research did not demonstrate the
effectiveness of psychotherapy. In his landmark Psychological Bulletin article,
“Some Myths of Psychotherapy Research and the Search for a Paradigm”
(Kiesler, 1966), he synthesized previous rebuttals of Eysenck’s position into a
cogent position paper, and he charted the course for the type of research that
would be needed to challenge Eysenck’s negative conclusions.
In this article he examined a number of myths in psychotherapy research
that he believed continually led psychotherapy researchers to reach the wrong
(negative) conclusion about the value of psychotherapy. A key myth was
the patient uniformity myth. Kiesler argued that it was inappropriate to lump
patients with different types of problems in the same research sample, arguing
instead that research samples should isolate patient groups by type. He also
focused on the therapist uniformity myth—the assumption that “therapists are
more alike than different and that whatever they do with their patients may
be called ‘psychotherapy’” (Kiesler, 1966, p. 112).
Kiesler thus dismissed the question “Does psychotherapy work?” as naive
and reframed the field of psychotherapy research around the question “What
works for whom?” His 1966 article became one of the most widely cited articles
DONALD J. KIESLER 213

in psychotherapy research (later identified as one of 12 “classic” articles in clin-
ical psychology by the journal Clinician’s Research Digest) and helped unleash a
flood of efforts to begin researching psychotherapy in a more nuanced fashion.
It continues to exert a guiding influence on psychotherapy research to this day.
Kiesler’s book, The Process of Psychotherapy: Empirical Foundations and
Systems of Analysis (1973), constituted another landmark contribution to
psychotherapy research methodology. He had previously contributed to
methodological and measurement advances in psychotherapy process research,
and his 1966 “Myths” article had decried the “misconception” that “process
research is not outcome research and outcome research is not process research”
(p. 126). The book attempted to remedy this lack of attention to process
research by providing a conceptual and methodological framework that
would serve to substantially guide the next generation of psychotherapy
process researchers (Greenberg & Pinsof, 1986). In addition to providing a
comprehensive review of the major psychotherapy process coding systems
existing at the time, the book questioned the traditional distinction between
process and outcome, arguing that this distinction had led to an almost exclu-
sive (and unfortunate) focus on two measurement points: pretreatment and
postreatment. Instead, Kiesler argued for the importance of conceptualizing
changes occurring throughout the course of treatment as “sub-outcomes”—a
perspective that continues to guide contemporary psychotherapy researchers.
The book also provided a vitally important discussion of a number of critical
methodological issues, including the unit problem, sampling issues, training
and clinical sophistication of judges, and assessment of interrater reliability.
Communications Analysis and Interpersonal Theory
One of the factors stimulating Kiesler’s interest in communication analy-

sis and interpersonal theory was a perception that the Wisconsin research team
had developed that therapist congruence can play an important role in the
treatment of schizophrenia. Another factor was his perception that incongru-
ent communications within the Wisconsin research team exacerbated con-
flict that may have been resolvable had it been openly addressed. In this
context, Kiesler turned to communications analysis, analyzing discrepancies
between overt and covert communications and their influence on developing
relationships. He focused on how nonverbal messages exerted strong influence
in defining the developing relationship between two parties, often outside of
their awareness, in ways that they could neither identify nor defend against.
Investigation of the role that communication played in shaping relationships
led him to the works of interpersonal psychologists such as Timothy Leary
and the Kaiser team that he was a part of, as well as works by Bob Carson and
Jerry Wiggins. Synthesizing interpersonal psychology with the communica-

tions focus of Ernst Beier (1966) and others, Kiesler concluded that individ-
uals’ psychological and behavioral patterns are largely created and sustained
in interpersonal relationships through patterned interaction cycles.
Following Beier, Kiesler argued that individuals create stability in relation-
ships through the use of unconscious evoking messages that function to con-
strain the others’ reactions to those that are predictable and comfortable for the
individual. He became interested in studying the “receiving” end of communi-
cations, and theorized a counterpart to the sender’s evoking message in the form
of a receiver’s impact message. Kiesler theorized that covert impact messages
included elements of feelings, action tendencies (impulses to respond in spe-
cific ways), fantasies, and attributions (about the evoking person’s intent, char-
acter, etc.). He and his team developed the Impact Message Inventory (IMI)
to measure impacts corresponding to the interpersonal circle categories. The
IMI has been used in more than 100 studies of the propositions of interpersonal
theory, the interpersonal elements of depression, personality disorders and
other psychopathologies, and interpersonal processes in psychotherapeutic and
other relationships (Kiesler, 2001b).
His work with the IMI spurred Kiesler to delve deeper into the inter-
personal circle tradition, resulting in his intricate 1982 Interpersonal Cir-
cle taxonomy in which he integrated the numerous previous theoretical and
empirical versions of the circle (Kiesler, 1983). The circumplex he constructed
was highly detailed, included both normal and abnormal levels, and resulted
in the publication of another instrument, the Checklist of Interpersonal
Transactions (CLOIT), used in over 50 studies of interpersonal transac-
tions in psychotherapy, including studies on countertransference, therapeutic
alliance, patient–therapist matching, metacommunication, and group therapy
interactions (Kiesler, 2001a).
Kiesler became intrigued by and expanded on Leary’s (1957) notion of
interpersonal reflexes and Carson’s later (1969) circumplex-based proposi-
tions regarding the principle of interpersonal complementarity. The concept
of complementarity suggests that individuals in ongoing relationships tend to
mutually reinforce one another’s behavior, emotions, perceptions, and per-
spectives. In regard to the interpersonal circle, the complementarity hypoth-
esis is that friendly behaviors complement friendly behaviors (and hostile,
hostile), and that dominant behaviors complement submissive behaviors
(and vice versa). Relationships are hypothesized to be most stable and mutu-
ally reinforcing when two individuals’ trait styles are complementary to one
another. When their trait styles are not complementary, they rely on evok-
ing messages that tend to pull for complementary responses as a means of try-
ing to alter partners’ behavior (and thus the relationship) toward behavior
that is reinforcing to their own preferred style. Thus, if a person with high
trait friendliness is in a relationship with a person whose base style is colder,

each will try to evoke reactions that are more fitting with their preferred
style—the friendly person will try to use warm, friendly, engaging, and agree-
able behaviors to try to pull her partner toward a closer, more affiliative rela-
tionships, whereas the colder partner will likely use indifferent or hostile
behaviors to try to establish greater relational distance between the two, con-
sistent with that person’s comfort zone.
In a burst of activity in the early 1980s, Kiesler synthesized concepts
from communications analysis, the interpersonal circumplex assessment tra-
dition, personality development theory, and behavioral, client-centered, and
relational therapies into what he referred to as an interpersonal manifesto and
a structured therapy—interpersonal communications psychotherapy. Across
two chapters in the groundbreaking Handbook of Interpersonal Psychotherapy
(Kiesler, 1982a, 198b), he laid the foundation for the work he would engage
in for the remainder of his career. He first summarized the radical conceptual
framework established by Harry Stack Sullivan (1953), in which the concept
of “individuals” is seen as a Western cultural abstraction, and personality is
seen primarily as “the relatively enduring pattern of recurrent interpersonal
situations that characterize a human life” (pp. 110–111).
Kiesler went on to synthesize elements of what he saw as the four branches
of post-Sullivanian development of interpersonal theory: (a) family communi-
cations theory and resultant family therapy approaches, (b) the study of non-
verbal communication, (c) the study of interpersonal behavior, and (d) the
social psychological study of interpersonal interactions. Kiesler’s synthesis of
these various branches resulted in directing psychological and psychotherapeu-
tic study toward interactionism (with interpersonal transactions rather than
individuals as the basic unit of study), circular causality rather than linear
causality (interactants are simultaneously influencing and being influenced,
and this context is required to examine individual behaviors of either), phe-
nomenology (covert experiences are a central element of interactions and must
be studied along with overt behavior), and use of the interpersonal circle model
as a conceptual map for considering social behavior.
Part II of his interpersonal manifesto defined psychopathology from an
interpersonal perspective and laid the foundation for psychotherapy that directly
addresses clients’ “disordered, inappropriate, or inadequate interpersonal com-
munications” (Kiesler, 1982b, p. 13). Rather than focusing on internal factors
such as maladaptive thoughts and feelings in an isolated manner, Kiesler focused
on the interpersonal context in which those thoughts and feelings occur. Indi-
vidual psychopathology is conceptualized in relation to maladaptive transaction
cycles between the person and significant others that cause it, sustain it, and are
shaped by it. Causality is not linear but circular. For example, an individual’s
depression may have roots in past experiences (e.g., others who treated the per-
son poorly, thwarted the person’s autonomy), but the depression also elicits char-

acteristic reactions of others (e.g., to tell the person to “look on the bright side”),
which then sustain and reinforce the depression (because the person can’t
simply “cheer up” and becomes frustrated by hearing this). Over time, others
may lose patience and begin challenging the person (e.g., “You always seem
to see the glass as half empty”), distancing or avoiding the person alto-
gether. The person is likely to have negative reactions to this outcome and
become more withdrawn and pessimistic as a result. From Kiesler’s point of
view, to conceptualize depression (or other psychopathologies) decontex-
tualized from interpersonal interactions was to deprive the conceptualiza-
tion of its most important elements.
Like Leary (1957), Kiesler emphasized that when a person interacts
rigidly (with little variation in style across situations) or extremely (intensely
displaying a particular style within a situation, beyond a level that would be
appropriate to the situation at hand), that person’s inflexible and intense
behavior significantly constrains others’ reactions. Thus, not only do social
interactions serve as reinforcers for an individual’s maladaptive behaviors,
but the person’s own interactional style unduly influences and shapes
others’ reactions directly toward those behaviors, which then sustain the
pathology. Because the person consciously attends to his or her verbal
behavior, and because the person’s influential nonverbal behavior is often
discrepant from his or her verbal behavior, the person “has little under-
standing of how he had come to or is responsible for this miserable state of
affairs” (Kiesler, 1982b, p. 13). Kiesler concluded that “the culprit in dis-
ordered behavior, therefore, is duplicitous communication” (p. 14) that
is in conflict with the person’s conscious self-definition, and of which the
person is largely unaware.
Interpersonal Communication Psychotherapy
Kiesler focused on the role of the therapist as another interactant in the

person’s social world. As another interactant, the therapist experiences pulls
and reactions that are similar to those experienced by others having relation-
ships with the client. Just as clients’ rigid and extreme interpersonal patterns
shape others’ reactions toward complementary responses that reinforce the
clients’ own cognitive, emotional, and behavioral patterns and troubled self-
identity, therapists are also shaped to react in these constrained and reinforc-
ing ways. Thus, therapists can determine how they are being constrained and
use this information to help clients change the patterns that constrain signif-
icant others, hopefully interrupting the cycle of mutual reinforcement that
leads to sustenance of clients’ pathology.
Kiesler developed his interpersonal communication psychotherapy
out of this basic model and identified therapeutic tasks across two stages of

therapy. In the first stage, labeled the engaged stage, the client intentionally
and unintentionally shapes the therapist
to respond to him from a restricted aspect of the therapist’s own internal
experience and behavior repertoire. . . . The therapist cannot not be
hooked or sucked in by the client, because the client is more adept, more
expert in his distinctive, rigid, and extreme game of interpersonal
encounter. (Kiesler, 1982a, p.281)
Thus, to begin the second therapeutic stage, the disengaged stage, the therapist’s
first task is to identify how the client is constraining him or her. The therapist
does this by noticing the experienced impact messages—the feelings, action
tendencies, attributions, and fantasies that the therapist experiences while
interacting with or imagining the client.
The therapist’s second task is to interrupt his or her automatic responses
to the client. If pulled to advise or comfort the client, the therapist notices
this and begins to withhold advice or comfort to interrupt the pattern of rein-
forcement of the client’s pathological style. The therapist then goes beyond
withholding automatic complementary responses to the client’s bids for rein-
forcement and begins engaging in asocial ways, intended to influence the
client to act differently because old behaviors no longer elicit predictable and
comforting reinforcement. Kiesler precisely defined these actions in relation
to the interpersonal circle model, identifying acomplementary and anti-
complementary responses that reject the client’s bid for reinforcement in
terms of either degree of affiliation or control in the relationship (or both).
As one particular type of asocial response, Kiesler focused extensively
on the process of metacommunication, in which the therapist draws explicit
attention to the verbal and nonverbal influencing behaviors of the client and
the role that they play in shaping in-session interactions as well as the
extratherapeutic social interactions that ultimately sustain the client’s prob-
lematic self-definition and relationship difficulties. The therapist prioritizes
client communications that directly refer to the therapist for feedback. The
therapist carefully focuses on both positives and negatives, being careful to
convey a supportive attitude and helpful intent. The therapist discloses the
impacts the client makes upon him or her and ties these impacts to specific
client actions to help the client understand how he or she influences others.
Then therapy explores the ways in which the client uses communication to
influence others besides the therapist, helping the client also explore how he
or she is in turn influenced by significant others’ communications.
Kiesler continued to develop this approach to psychotherapy over the
remainder of his career and featured it in his encyclopedic book Contempo-
rary Interpersonal Theory and Research (Kiesler, 1996). In this book, Kiesler
made a compelling case for interpersonal theory as one of psychology’s hall-

mark accomplishments, an underrecognized and underappreciated integra-
tive theory that logically and empirically ties together personality, psy-
chopathology, social interaction, assessment and diagnosis, psychotherapy,
and clinical supervision. Kiesler saw interpersonal theory as bridging the
subdisciplines of personality and social psychology with those of clinical
and counseling psychology, with the potential to contribute toward the uni-
fication of psychology.
CONCLUSION
Donald Kiesler contributed significantly to the field of psychology over

his 45-year career. From his early work on psychotherapy process research and
linking process with outcomes, through his widely heralded work identifying
uniformity myths in psychotherapy research and introducing a focus on “what
works for whom” in place of the discarded question “Does psychotherapy
work?” he helped set the stage for modern psychotherapy research. His syn-
thesis of knowledge on process and outcomes research in the early 1970s laid
a solid foundation for the next generation of psychotherapy researchers to
build on. His synthesis of communications theory, early interpersonal theory,
and social interactions research into a fully realized modern interpersonal the-
ory left the field a complex system with strong empirical grounding that can
be mined for years to come. His work on therapeutic metacommunication
and interpersonal psychotherapy anticipated trends in the field of psycho-
therapy by many years (e.g., the relational tradition in contemporary psycho-
analysis), and in this respect he was remarkably prescient.
Kiesler’s work influenced and was influenced by other contemporary
researchers, such as Hans Strupp, Paul Wachtel, and Jerry Wiggins. His
work also significantly influenced (and in turn was influenced by) Jeremy
Safran and colleagues’ work on interpersonal process in psychotherapy and
alliance ruptures (e.g., Safran & Muran, 2000; Safran & Segal, 1990), James
McCullough’s cognitive–behavioral analysis system of psychotherapy for
chronic depression (McCullough, 2003), and a host of interpersonal person-
ality and psychotherapy researchers (e.g., Lynn Alden, Timothy Anderson,
Michael Gurtman, Anton Hafkenscheid, Leonard Horowitz, Stan Murrell,
Aaron Pincus, Stan Strong, and Terry Tracey).
We believe it would be a mistake to conclude without at least mention-
ing the human aspects of his legacy. For many people Don Kiesler was a
uniquely supportive and engaged mentor with an unparalleled ability to bring
out the best in them. Regardless of what form his mentorship assumed, his
personal qualities played an incalculably important role in transforming many
people’s professional lives.

REFERENCES
Beier, E. G. (1966). The silent language of psychotherapy: Social reinforcement of uncon-

scious processes. Chicago, IL: Aldine.
Carson, R. C. (1969). Interaction concepts of personality. Chicago, IL: Aldine.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of
Consulting and Clinical Psychology, 16, 319–324.
Greenberg, L., & Pinsof, W. (1986). The psychotherapeutic process. A research hand-
book. New York, NY: Guilford Press.
Kiesler, D. J. (1966). Some myths of psychotherapy research and the search for a
paradigm. Psychological Bulletin, 65, 110–136. doi:10.1037/h0022911
Kiesler, D. J. (1973). The process of psychotherapy: Empirical foundations and systems of
analysis. Chicago, IL: Aldine.
Kiesler, D. J. (1982a). Confronting the client–therapist relationship in psychotherapy.
In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy
(pp. 274–295). Elmsford, NY: Pergamon.
Kiesler, D. J. (1982b). Interpersonal theory for personality and psychotherapy. In
J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy
(pp. 3–24). Elmsford, NY: Pergamon.
Kiesler, D. J. (1983). The 1982 Interpersonal Circle: A taxonomy for complementar-
ity in human transactions. Psychological Review, 90, 185–214. doi:10.1037/0033-
295X.90.3.185
Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality,
psychopathology, and psychotherapy. New York, NY: Wiley.
Kiesler, D. J. (2001a). Empirical studies that used the Checklist of Interpersonal/
Psychotherapy Transactions: An annotated bibliography. Retrieved from
http://www.vcu.edu/sitar/cloit.pdf
Kiesler, D. J. (2001b). Empirical studies that used the Impact Message Inventory: An
annotated bibliography. Retrieved from http://www.vcu.edu/sitar/imi.pdf
Leary, T. (1957). Interpersonal diagnosis of personality. New York, NY: Wiley.
McCullough, J. P. (2003). Treatment for chronic depression: Cognitive behavioral analy-
sis system of psychotherapy (CBASP). New York, NY: Guilford Press.
Rogers, C. R., Gendlin, E. T., Kiesler, D. J., & Truax, C. B. (1967). The therapeutic
relationship and its impact: A study of psychotherapy with schizoprenics. Madison:
University of Wisconsin Press.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York, NY: Guilford Press.
Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New
York, NY: Basic Books.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton.

19
LORNA SMITH BENJAMIN: LOVE,
LOYALTY, AND LEARNING IN CLOSE
ATTACHMENT RELATIONSHIPS
KENNETH L. CRITCHFIELD
I love to work with seriously troubled people who are driving everyone else
crazy and have been unresponsive to many previous treatments. . . . I want
to help relieve suffering. I want to see change in the patient’s personal life.
I want to see the patient rediscover delight and to thrive. I want patients
to become fully engaged in their lives to the best of their abilities. The best
reward for me is to see people who were once remarkable for causing trou-
ble, for being almost nonexistent, or for other unhappy reasons, learn to fly.
— (Benjamin, 2001, p. 27).
Lorna Smith Benjamin is a master clinician and preeminent scientist–

practitioner known for her work to help people with severe and complex
psychopathology. Her contributions have been far-reaching and profoundly
influential in psychotherapy research. In her work as a researcher, Benjamin’s
quest has been to articulate psychodynamic clinical theory and make it amen-
able to empirical testing. As a theorist she provides a comprehensive view of
psychopathology and a treatment approach based on attachment, interper-
sonal, and object relations theories. Her model of relational behavior has been
applied transtheoretically by many research groups to study psychiatric dis-
order and its treatment, as well as normative patterns of interaction.
MAJOR CONTRIBUTIONS
Benjamin’s primary accomplishments include the creation of the struc-

tural analysis of social behavior model (SASB; Benjamin, 1979, 1993/1996)
and development of an associated treatment approach, interpersonal recon-
structive therapy (IRT; Benjamin, 2003). She is an expert in the assessment
and treatment of personality disorder (PD), elaborating an interpersonal
221
approach to PD diagnosis (Benjamin, 1993/1996) and contributing substan-
tially to other assessment methods, including the Structured Clinical Interview
for the DSM–IV Personality Disorders (SCID-II; First, Gibbon, Spitzer,
Williams, & Benjamin, 1996), and the Wisconsin Personality Inventory
(WISPI; Klein et al., 1993).
Across her career, Benjamin has played many important roles, includ-
ing as an advisor to the DSM–IV work group on Axis II. She also contributed
to Fetzer Institute and National Institute of Mental Health–sponsored meet-
ings to explore inclusion of relational disorder in future Diagnostic and Statis-
tical Manual of Mental Disorders (DSM) systems (Benjamin, Wamboldt, &
Critchfield, 2006). She is a past president of the Society for Psychotherapy
Research (SPR) and was granted an honorary doctoral degree from the Uni-
versity of Umea, Sweden, for her work with SASB. She has received many
awards, including the Society for Personality Assessment’s Klopfer Award, for
outstanding long-term professional contributions to personality assessment, and
the Distinguished Research Career Award from SPR.
As a clinician, Benjamin is well-known for her work in treating patients
for whom standard interventions have not been sufficient to prevent repeated
hospitalizations and suicide attempts. IRT clinic trainees and hospital staff
observe her consultations directly as she develops a case formulation that makes
sense of patient pathology in light of the unique interpersonal history.
Benjamin’s approach uses SASB to identify repeating patterns in patient nar-
ratives and quickly narrow the focus to the most important themes. She views
psychopathology as reflecting failed attempts at adaptation using previously
internalized values and learning. In her view, maladaptive internalized patterns
often persist because they are driven by love and loyalty to the attachment fig-
ures with whom they were first learned. In the introduction to the 2006 edi-
tion of Interpersonal Reconstructive Therapy, she called this “attachment gone
awry” (Benjamin, 2003/2006, p. v) and had boldly asserted elsewhere that
“every psychopathology is a gift of love” (Benjamin, 1993). Her treatment
approach, IRT, directly addresses the relationship with these internalizations.
BEGINNINGS
Benjamin was born and raised in upstate New York, near Rochester. Her
father was a research chemist who later became an executive for the Eastman
Kodak Company. He was a major source of her lifelong fascination and respect
for the sciences. Early socialization on the family farm instilled values of hard
work, competence, and performance. It also brought early insight and attune-
ment to how relationships work. She described how in childhood she trained
and befriended an aggressive quarter horse that had been severely abused:
222 KENNETH L. CRITCHFIELD

I learned more about not being easily scared and, once again, to take
things slowly and with great patience. I also learned about the impos-
sibility of controlling another creature. The most you can do is per-
suade and negotiate your mutual interests as you move with the other.
(Benjamin, 2001, p. 29)
Having grown up studying music, Benjamin eventually attended the
Eastman School of Music and Oberlin College before shifting course to the sci-
ences. Her deep appreciation for practice, repetition, and attention to detail in
conservatory learning is now reflected in her approach to therapy training. Her
conviction is that the art of therapy can and should be grounded in a theory of
fundamental principles and taught to high levels of proficiency.
Professional Training
Benjamin began her graduate training at the University of Wisconsin in

1956. In 1960, she received her PhD in experimental psychology with a minor
emphasis in mathematical statistics. Her major professor was Harry Harlow.
Benjamin contributed to the famous studies on contact comfort and maternal
deprivation in rhesus monkeys. Her thesis and dissertation focused on the
impacts of hunger, frustration, and type of mother surrogate on thumb-sucking
in young primates. During her graduate training Benjamin met John Bowlby,
who was then conversing with Harlow about attachment theory. Benjamin’s
work was profoundly influenced by both Harlow and Bowlby, especially in
terms of the impact of early relationships on adult problems.
Benjamin would go on to receive clinical training with primary input from
psychodynamic and client-centered perspectives, including a brief period of
supervision by Carl Rogers. She also was influenced by Carl Whittaker’s
approach to family work and David Graham’s demonstrations of precise con-
nections between relational patterns and medical diseases (e.g., Graham et al.,
1962).
Benjamin had not been long in clinical practice when she began apply-
ing her scientific training to the psychotherapy process itself:
To try to figure out what really goes on, I began to take notes in transcript
form . . . . I wanted to have a record uncontaminated by my thoughts and
interpretations of what happened—raw data, so to speak. I wanted to be
able to look back at difficult sessions and track what happened the next
time. (Benjamin, 2001, pp. 22–23)
Across her career Benjamin has repeatedly emphasized the need for
well-articulated theory that can be tested directly with observable data. Like
Harlow, her preference is for direct demonstrations of principle in well-
designed experiments with few subjects. Reflecting her concern with the vital
LORNA SMITH BENJAMIN 223

role of theory and method in testing clinical hypotheses, Benjamin’s early pub-
lications included a mathematical defense of the use of covariance to adjust for
the impact of the law of initial values in psychophysiology studies (Benjamin,
1967). In another article (Benjamin, 1965), she used modular algebra to defend
the legitimacy of the allegedly fatal confounds in the Latin square design. That
dispelled, she suggested that the Latin square is an ideal paradigm for using each
subject as his or her own control in psychotherapy studies. Her careful self-study
of psychotherapy process would eventually result in SASB, which she has
referred to as a “periodic table of the elements for relating” (Benjamin, 2001),
as well as her treatment approach, IRT.
ACHIEVEMENTS
Charting Relational Behavior With SASB
When first described in Westman’s Individual Differences in Children

(Benjamin, 1973), SASB was humbly referred to as a “chart” to organize the
basic elements of social relating in primates. From a formal and theoretical per-
spective, however, SASB was a powerful integration of competing rela-
tional models developed by Leary (1957) for adults and by Schaefer (1965)
for parent–child interactions. SASB organizes interpersonal and intrapsychic
behavior with three basic dimensions: focus, affiliation, and interdependence.
Each of these dimensions is seen as having evolved to enhance biological sur-
vival of primates. The model is represented as three circular, or “circumplex,”
arrangements of behavior. The focus distinction specifies which circle a behav-
ior is located on according to whom a behavior is to, for, or about. Focus
includes transitive focus on the other, intransitive focus on the self (in relation
to the other), or introjective focus on the self by the self. For each focus, a hor-
izontal dimension shows the degree of affiliation (love vs. hate) and a vertical
dimension traces the degree of enmeshment (control/submit) versus differen-
tiation (emancipate/separate). Labels are provided for behaviors around the
perimeter of the model, each representing a precise combination of the three
underlying dimensions. For example, the behavior “protect” involves focus on
another person that involves moderate affiliation and moderate control. Since
it is possible for behavior to be at once hostile and friendly, enmeshed and sep-
arate, or focused on both self and other, such “complex” behaviors are repre-
sented by more than one simultaneous position on the model.
SASB has been elaborated to varying degrees of specificity, from simple
division into quadrants, to a full model with 36 points articulated for each focus
(Benjamin, 1979). The octant model has a medium degree of specificity and is
the most commonly used version (Benjamin, 1993/1996). In addition to the

focus on behavior, Benjamin proposed parallel models of affect and cognition
that involve the same basic structure (described in Benjamin, 2003/2006). As
a descriptive framework for human interaction, SASB has obvious application
to clinical work, including the study of therapy process, relational patterns asso-
ciated with psychopathology, family dynamics, and much more.
SASB has undergone extensive validation and testing to confirm the
structure and reliability of the model (reviews of validity and application in
multiple settings are available in Benjamin, 1993/1996; Benjamin, Rothweiler,
& Critchfield, 2006; Constantino, 2000). It has been used extensively in both
research and clinical settings as an observational coding system (Benjamin &
Cushing, 2000) and as a self-report questionnaire (Intrex; Benjamin, 2000).
SASB has been translated into 14 languages and used by diverse research groups
to test theories of clinical pathology, case formulation, patient and therapist
attachment histories, and couples interactions. In psychotherapy research,
SASB has been used to study relational outcomes and in-session processes in
psychodynamic (e.g., Henry, Schacht & Strupp, 1990), cognitive–behavioral
(e.g., Critchfield, Henry, Castonguay, & Borkovec, 2007; Shearin & Linehan,
1992; Vittengl, Clark, & Jarrett, 2004), and humanistic therapies (e.g., Paivio
& Greenberg, 1995).
Defining Normal Interpersonal Relating and Specifying Common

Interactional Patterns
Benjamin (2003/2006) used SASB to precisely define adaptive, normal

relating as having a flexible baseline that is appropriate to context but prima-
rily involves friendliness, moderate enmeshment, moderate differentiation,
and a balance of focus on self and others. By contrast, psychopathology is char-
acterized by baselines involving hostility, extremes of enmeshment or differ-
entiation, imbalance of focus, or rigid responding that is not responsive to
circumstance. Normative data on the SASB-based Intrex questionnaire sup-
port this definition for normal and patient samples, as do numerous studies asso-
ciating interpersonal hostility with psychopathology. Benjamin proposed that
relational disorder is diagnosable as any significant deviation from normative
relating with significant others (Benjamin, Wamboldt, & Critchfield, 2006).
Benjamin uses SASB to specify the dyadic interaction patterns, or “pre-
dictive principles,” of similarity, complementarity, introjection, opposition, and
antithesis. Similarity is defined by identical positioning of two people on the
model, such as in sequences of control and countercontrol. Complementary
behaviors also share the same dimensionality, but they differ in terms of focus.
For example, if one partner is controlling, it invites the other to complement
with submission; as another example, affirmation (friendly autonomy-granting)
invites open disclosure (friendly separateness). Complementary interactions are

thought to be relatively stable because each behavior pulls for the other in
self-reinforcing cycles.
The predictive principle of introjection is defined as self-treatment that
reflects actions of another. For example, a student who may be feeling hope-
ful about academic pursuits is told by an important family member that she
has always been a disappointment. If the student responds to this critical
input with self-criticism and the belief that she will now fall short in her
studies, it has been introjected. Opposites are behaviors that share behavioral
focus but are positioned 180 degrees apart. Antitheses are maximally differ-
ent on all three SASB dimensions. Opposition and antithesis also have clin-
ical relevance. For example, if a patient begins a session by sulking and
complaining about the therapist or therapy (hostile, self-focused enmesh-
ment), the SASB-defined antithesis would be to nondefensively affirm the
patient’s point of view as important (friendly, other-focused autonomy-
granting), and through the principle of complementarity invite open disclo-
sure (the opposite of sulking: friendly focus on self that is moderately separate)
to regain collaboration.
When complex codes are included along with SASB’s predictive prin-
ciples, it becomes possible to identify double binds, ambivalence, and mixed
messages of many kinds, as well as to trace their impact on unfolding inter-
actional sequences. A great deal of sophistication can thus be captured by
SASB’s three simple distinctions. Benjamin has written extensively on how
to apply SASB to both research and clinical work in couples, families, and
groups. In a novel application, she has even shown that diagnostic categories
involving auditory hallucinations (schizophrenia, mania, psychotic depres-
sion, borderline personality) can be differentiated by the quality of the rela-
tionship with the voices (Benjamin, 1989). Beyond this, Benjamin (1986)
has offered powerful statistical approaches for studying relational patterns,
including sequential analysis with Markov chains. Vividly demonstrating the
importance of sequence in psychotherapy sessions, Karpiak and Benjamin
(2004) showed that therapist affirmation may have very different impacts on
outcome, depending on whether it follows adaptive or maladaptive patient
content.
Interpersonal Diagnosis of Personality Disorder
In 1993, Benjamin published a comprehensive interpersonal diagnostic

framework for the DSM PDs, now in its second edition (1996). This book was
a monumental achievement, contributing significantly to identification and
treatment of PDs. Her method provided a concrete picture of prototypic rela-
tional patterns, interpersonal learning histories, wishes and fears, needed inter-
personal learning, and expectable processes in the treatment of each PD. As

an example, the prototypic interpersonal summary of obsessive–compulsive
PD is:
There is a fear of making a mistake or being accused of being imperfect.
The quest for order yields a baseline interpersonal position of blaming and
inconsiderate control of others. The OCD’s control alternates with blind
obedience to authority or principle. There is excessive self-discipline, as
well as restraint of feelings, harsh self-criticism, and neglect of the self.
(1993/1996, p. 247).
Each statement in the description occupies a precise location on the

SASB model. Her method reduces diagnostic overlap between categories
through clear specification of patterns plus the use of interpersonal necessary
and exclusionary criteria. Early histories are described in parallel SASB
terms and provide a bridge to the relational learning history. Tests of SASB-
defined links between interpersonal history and adult pathology have held
up well for PDs with adequate representation in study samples (Smith, Klein,
& Benjamin, 2003).
Interpersonal Reconstructive Therapy (IRT)
In her first book (Benjamin, 1993/1996), Benjamin provided an outline

for tailoring treatment to address each category of PD. She also offered an
approach to treating less common personality patterns falling under the not
otherwise specified label. Her method emphasized internalized relational patterns
measurable with SASB. This individually tailored approach to psychotherapy
would later be elaborated as IRT.
IRT is organized around two core ideas that grew directly out of work
with the SASB model: copy process theory and the gift of love. Copy processes
are imitative connections to important attachment figures such as parents,
romantic partners, siblings, grandparents, teachers, religious leaders, and so on.
Imitative repetition of internalized relationships is thought to reflect a norma-
tive process of attachment. It is also thought to be a powerful and ubiquitous
influencer of perception and behavior. Copy processes become problematic
when effective adaptation is compromised because a person is responding to
internalizations of important persons more than to present-day reality. It is in
this sense that Benjamin referred to psychopathology as “attachment gone
awry” (Benjamin, 2003/2006, p. v).
Copy processes are detectable as repeating patterns of thought, feeling,
and behavior that parallel those experienced with important others. The copy-
ing is measurable with SASB and takes three primary forms: identification (be
like the other person), recapitulation (behave as if the other person is still pres-
ent and in charge), and introjection (treat the self as he or she did). Critchfield

and Benjamin (2008) provided evidence that the three primary forms of copy
process are detectable in both normal and clinical samples, involve behavior
from all around the SASB model, and show variability by clinical status, gen-
der, and which early figures are copied.
The gift of love hypothesis states that copy processes are ultimately
maintained, even when obviously maladaptive, by attachment-based desires
to receive love and acceptance from the internalized figures. The gift is inher-
ent in copy process repetitions. As Benjamin wrote, it is as if the message to
the internalized loved one is “If I do this well enough, long enough, faithfully
enough, then maybe you will love me” (2003/2006, p. 49). Understanding
psychopathology as an ongoing, internalized, relationship process, IRT directly
addresses conflict between the part of a patient loyal to the internalized
rules and values (termed the Regressive Loyalist) and the part that seeks flex-
ible, adaptive, healthy relating with self and others (the Growth Collaborator).
Awareness of the repeating patterns, where they come from, and what they are
for, enhances the patient’s ability to choose a reworking of attachments,
including grief over losses and unfulfilled wishes for reconciliation and accept-
ance. This in turn creates space for pursuit of more adaptive, fulfilling ways of
experiencing and being.
Setbacks and conflicts in the change process of therapy are predictable
as a result of what Benjamin recently described as IRT’s “autoimmune theory
of psychiatric disorder” (Benjamin, 2008). According to this theory, moves
toward more healthy adaptation can be perceived as threatening the connec-
tion to internalized figures. A resulting pattern of self-attack in response to this
threat is similar to autoimmune disorders in which healthy cells are destroyed
when misidentified as dangerous. Significant regressions to self-destructive pat-
terns are seen as reflecting attempts by the Regressive Loyalist part of the self
to stay close to important attachment figures. This view is fundamentally inter-
active in nature, explicitly frames psychopathology as a misdirected attempt at
adaptation, and stands in sharp contrast to what Benjamin called the “broken
brain” theory of psychopathology (2008). In light of the autoimmune theory,
IRT is a long-term approach that requires a strong therapeutic collaboration to
both motivate and support patients through the difficult work of defying inter-
nalizations and developing healthier patterns and self-concepts.
Ongoing IRT Research
Benjamin remains very active in research activities to test the efficacy

and proposed mechanisms of change in IRT at the University of Utah
Neuropsychiatric Institute. Preliminary findings include that the SASB-based
case formulation is reliable (Hawley, Critchfield, Dillinger, & Benjamin,
2005) and discriminates well among cases. Significant associations have been

found between adherence to IRT principles and outcome, especially for inter-
ventions focused on the gift of love (Critchfield, Davis, Gunn, & Benjamin,
2008). Pre–post comparisons over 1 year with patients referred for chronic and
severe psychopathology show significant reductions in suicidality, hospitaliza-
tions, and days hospitalized compared with the year before IRT (Critchfield,
Benjamin, Hawley, & Dillinger, 2006). Ever pushing forward, Benjamin is
now preparing a book geared toward helping clinicians engage a patient’s will
to change, based on empirical findings from the IRT clinic about the central
importance of focus on the gift of love to change persistent psychopathology.
CONCLUSION
Benjamin’s work brings together all of the early themes in her life, refined
and enhanced through roughly 50 years of clinical experience and careful
research. These themes most crucially involve attunement to relationship pat-
terns or what she has referred to as “the harmonics of therapy” (Benjamin,
1993/1996), the importance of attachment as fundamental to our evolutionary
heritage, and a sharp focus on empirical data organized by her periodic table of
interpersonal relating. For Benjamin, psychopathology is about love, or more
precisely about love gone wrong. Her theory offers a profoundly humanizing
view of psychiatric disorder and is backed up with compelling data. She sum-
marized her view succinctly: “Psychopathology is best attributed to broken
hearts (attachment gone awry) rather than to broken brains” (Benjamin, 2008,
p. 414). According to Benjamin, when the past is reckoned with and impossi-
ble wishes successfully grieved, patients can revise impacts of abuse, neglect,
and other toxic patterns. They then have the opportunity to learn new, more
adaptive skills, and in this respect “learn to fly.”
REFERENCES
Benjamin, L. S. (1965). A special Latin Square for the use of each subject “as his own
control.” Psychometrika, 30, 499–513.
Benjamin, L. S. (1967). Facts and artifacts in using Analysis of Covariance to “undo”
the Law of Initial Values. Psychophysiology, 4, 187–206.
Benjamin, L. S. (1973). A biological model for understanding the behavior of indi-
viduals. In J. Westman (Ed.), Individual differences in children (pp. 215–241). New
York, NY: Wiley.
Benjamin, L. S. (1979). Structural analysis of differentiation failure. Psychiatry, 42, 1–23.
Benjamin, L. S. (1986). Operational definition and measurement of dynamics shown
in the stream of free associations. Psychiatry, 49, 104–129.

Benjamin, L. S. (1989). Is chronicity a function of the relationship between the per-
son and the auditory hallucination? Schizophrenia Bulletin, 15, 291–310.
Benjamin, L. S. (1993). Every psychopathology is a gift of love. Psychotherapy Research,
3, 1–24.
Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders
(2nd ed.) New York, NY: Guilford Press. Originally published in 1993.
Benjamin, L. S. (2000). Intrex user’s manual. Salt Lake City: University of Utah.
Benjamin, L. S. (2001). A developmental history of a believer in history. In M. R.
Goldfried (Ed.), How therapists change: Personal and professional reflections
(pp.19–35). Washington, DC: American Psychological Association. doi:10.1037/
10392-002
Benjamin, L. S. (2006). Interpersonal reconstructive therapy: A personality-based treat-
ment for complex cases. New York, NY: Guilford Press. Paperback with new sub-
title and introduction. Originally published in 2003.
Benjamin, L. S. (2008). What is functional about functional autonomy? Journal of
Personality Assessment, 90, 412–420. doi:10.1080/00223890802248596
Benjamin, L. S., & Cushing, G. (2000). Reference manual for coding social interactions in
terms of Structural Analysis of Social Behavior. Salt Lake City: University of Utah.
Benjamin, L. S., Rothweiler, J. C., & Critchfield, K. L. (2006). The use of Structural
Analysis of Social Behavior (SASB) as an assessment tool. Annual Review of
Clinical Psychology, 2, 83–109. doi:10.1146/annurev.clinpsy.2.022305.095337
Benjamin, L. S., Wamboldt, M. Z., & Critchfield, K. L. (2006). Defining relational
disorders and identifying their connections to Axes I and II. In D. J. Kupfer,
M. B. First, & D. E. Regier (Eds.), Relational processes and DSM-V: Neuroscience,
assessment, prevention and intervention (pp.157–173). Washington, DC: American
Psychiatric Press.
Constantino, M. J. (2000). Interpersonal process in psychotherapy through the lens
of the Structural Analysis of Social Behavior. Applied & Preventive Psychology,
9, 153–172. doi:10.1016/S0962-1849(05)80002-2
Critchfield, K. L., & Benjamin, L. S. (2008). Repetition of early interpersonal expe-
riences in adult relationships: A test of copy process theory in clinical and non-
clinical settings. Psychiatry, 71, 72–93.
Critchfield, K. L., Benjamin, L. S., Hawley, N., & Dillinger, R. J. (2006, June).
Attempted replication of effectiveness for Interpersonal Reconstructive Therapy
(IRT) to reduce hospitalizations and suicide attempts in “nonresponder” patients.
Presented to the Society for Psychotherapy Research, Edinburgh, Scotland.
Critchfield, K. L., Davis, M. J., Gunn, H. E., & Benjamin, L. S. (2008, June). Measuring
therapist adherence in Interpersonal Reconstructive Therapy: Conceptual frame-
work, reliability, and validity. Presented to Society for Psychotherapy Research,
Barcelona, Spain.
Critchfield, K. L., Henry, W. P., Castonguay, L. G., & Borkovec, T. D. (2007). Inter-
personal process and outcome in variants of cognitive-behavioral psychotherapy.
Journal of Clinical Psychology, 63, 31–51. doi:10.1002/jclp.20329

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1996).
Structured Clinical Interview for the DSM-IV Axis II Personality Disorders (SCID-II).
New York, NY: New York State Psychiatric Institute.
Graham, D. T., Lundy, R. M., Benjamin, L. S., Kabler, J. D., Lewis, W. C., Kunish,
N. W., & Graham, F. K. (1962). Specific attitudes in initial interviews with
patients having different “psychosomatic” diseases. Psychosomatic Medicine, 25,
260–266.
Hawley, N., Critchfield, K. L., Dillinger, R. J., & Benjamin, L. S. (2005, June). Case
formulation in Interpersonal Reconstructive Therapy: Using SASB and copy
process theory to reliably track repeating interpersonal themes. Poster presented
to the Society for Interpersonal Theory and Research, Montreal, Canada.
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient and therapist introject,
interpersonal process, and differential psychotherapy outcome. Journal of Con-
Karpiak, C. P., & Benjamin, L. S. (2004). Therapist affirmation and the process and
outcome of psychotherapy: Two sequential analytic studies. Journal of Clinical
Psychology, 60, 659–676. doi:10.1002/jclp.10248
Klein, M. H., Benjamin, L. S., Rosenfeld, R., Treece, C., Husted, J., & Greist, J. H.
(1993). The Wisconsin Personality Disorders Inventory: I. Development, reli-
ability, and validity. Journal of Personality Disorders (Suppl. 1), 18–33.
Leary, T. (1957). Interpersonal diagnosis of personality: A functional theory and method-
ology for personality evaluation. New York, NY: Ronald Press.
Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of
experiential therapy using empty-chair dialogue. Journal of Consulting and
Schaefer, E. S. (1965). Configurational analysis of children’s reports of parent behav-
ior. Journal of Consulting Psychology, 29, 552–557. doi:10.1037/h0022702
Shearin, E. N., & Linehan, M. M. (1992). Patient-therapist ratings and relationship
to progress in dialectical behavior therapy for borderline personality disorder.
Behavior Therapy, 23, 730–741. doi:10.1016/S0005-7894(05)80232-1
Smith, T. L., Klein, M. H., & Benjamin, L. S. (2003). Validation of the Wisconsin
Personality Disorders Inventory-IV with the SCID-II. Journal of Personality
Disorders, 17, 173–187. doi:10.1521/pedi.17.3.173.22150
Vittengl, J. R., Clark, L. A., & Jarrett, R. B. (2004). Self-directed affiliation and auton-
omy across acute and continuation phase cognitive therapy for recurrent dep-
ression. Journal of Personality Assessment, 83, 235–247. doi:10.1207/s15327752
jpa8303_07

20
DAVID E. ORLINSKY: DEVELOPING
PSYCHOTHERAPY RESEARCH,
RESEARCHING PSYCHOTHERAPIST
DEVELOPMENT
MICHAEL HELGE RØNNESTAD, ULRIKE WILLUTZKI,
AND MARGARITA TARRAGONA
David E. Orlinsky has taught since 1960 at the University of Chicago,

where he is a professor in the Department of Comparative Human Develop-
ment. He has coauthored two books, Varieties of Psychotherapeutic Experience
(Orlinsky & Howard, 1975) and How Psychotherapists Develop (Orlinsky &
Rønnestad, 2005), and coedited The Psychotherapist’s Own Psychotherapy:
Patient and Clinician Perspectives (Geller, Norcross, & Orlinsky, 2005). He
is the principal author of authoritative reviews of research on therapeutic
process and outcome that have appeared as chapters in the Handbook of
Psychotherapy and Behavior Change (Orlinsky & Howard, 1978; Orlinsky &
Howard, 1986a; Orlinsky, Grawe, & Parks, 1994; Orlinsky, Rønnestad, &
Willutzki, 2004). He has authored or coauthored more than 100 original jour-
nal articles and book chapters. He also practiced psychotherapy in Chicago
for many years.
Orlinsky’s contributions to psychotherapy research can be summarized
under five headings: (a) pioneering empirical studies of patients’ and therapists’
experiences in sessions and in the intervals between sessions, as well as
groundbreaking studies of psychotherapist development; (b) constructing
comprehensive, conceptually informed research instruments; (c) advanced
scholarship resulting in often-cited research reviews; (d) developing the
233
integrative, research-based generic model of psychotherapy; and (e) cofound-
ing and organizing the Society for Psychotherapy Research (SPR), which he
continues to sustain as a vital community of researchers at the national, inter-
national, and local levels.
David Orlinsky has received formal recognition for distinguished scientific
and professional contributions through awards from the American Psychologi-
cal Association (APA) Division of Psychotherapy, the Illinois Psychological
Association, and SPR, and he received an award for teaching excellence from
the University of Chicago. For nearly 5 decades he has influenced generations
of undergraduate and graduate students and has supervised, mentored, and
inspired numerous doctoral students and younger colleagues nationally and
internationally within the field of psychotherapy research.
EARLY BEGINNINGS
David Orlinsky was born in 1936 in New York City, the first child of his
parents and the first grandchild and nephew in a large, close-knit, upwardly
mobile working-class family of East European Jewish background. Looking
back at his origins (Orlinsky, 2005), he noted that having parents who were
also first-born meant that his youngest uncles and aunts were as close as or
closer in age to him than to his parents, which effectively put him between
generations. In relating “up” to his elders, he received much attention and
affection but was clearly not one of them. In relating “down” to cousins and
brother, he was naturally a leader, a “first among equals.” In this early family
environment, he learned to value close personal relationships and close-knit
groups, and he gained an awareness of complexity and context, an ability to
view questions from multiple perspectives, and a heightened sensitivity to
issues of inclusion and exclusion—traits that we think have influenced his
work in the field of psychotherapy.
Orlinsky received his elementary and secondary education at public
schools in New York, where his interest and talent in science and poetry were
nurtured. After high school, he attended the College of the University of
Chicago (1953–1954) where a coherently organized curriculum and com-
mitted teachers introduced him to classical works in the fields of humani-
ties, social science, and the physical and biological sciences. Next, he studied
in the University of Chicago’s master’s program on the history of culture
(1954–1955) and won an award for excellence in humanities and first prize
in the university’s poetry contest. Thereafter, he transferred to the Univer-
sity of Chicago’s doctoral program in clinical psychology (1955–1962), where
he met his classmate Kenneth Howard, who was to become his lifelong friend
and research partner.
234 RØNNESTAD, WILLUTZKI, AND TARRAGONA

The friends trained and had internships together in clinical psychology
but did not do psychotherapy research when they were students. It was not
until after graduation, when they worked part-time as staff therapists at an
outpatient clinic, that they started their first major study of psychotherapy,
which they called the Psychotherapy Session Project. What finally brought
them to do psychotherapy research? David wrote (Orlinsky, 2005, p. 1004):
“We did that, I confess, mainly as an excuse to continue seeing each other
after graduating.”
They described the influence that their graduate school training had on
their early work thus:
We had been educated in a properly but not narrowly positivistic spirit in
the graduate program. . . . We learned our Hull, Tolman, Guthrie, and
Skinner; but we were also exposed to Freud, Allport, Murray, and Lewin,
and the phenomenological, client-centered concerns of Carl Rogers and his
colleagues at the University’s Counseling Center. . . . [Rogers and his group]
provided the strong assumption that experience could and should be made
the subject of psychological science, even if they did not furnish a fully
appropriate research methodology. Our approach to the latter was undoubt-
edly influenced by the work of another eminent Chicago psychologist, L. L.
Thurstone, whose pioneering accomplishments in the psychometric scaling
of subjective qualities and attitudes provided the basis for attempting the
same sort of thing with participants’ experiences in psychotherapeutic ses-
sions [and whose pioneering work in factor analysis provided the basis for
their approach to data analysis]. (Orlinsky & Howard, 1986b, pp. 478–479)
ACCOMPLISHMENTS
Therapy Session Project and the Study of Therapeutic Experience
The Psychotherapy Session Project began with the development of a

postsession questionnaire for patients and therapists called the Therapy Ses-
sion Reports (TSR). Orlinsky and Howard (1986b) described their approach
as follows:
We began by reflecting on our own experiences in psychotherapy, as
therapists and as patients. We drew, of course, on our theoretical under-
standing of psychotherapy as a special kind of relationship, and more
generally on our broader understanding of personality and social relation-
ships. However, what we wanted were questions that were as purely
descriptive and noninferential—as close to the experienced “surface” of
events—as possible. We wanted questions about the most obvious fea-
tures of the experiences . . . that could be answered . . . without lengthy
reflection or calculation. (p. 479)
DAVID E. ORLINSKY 235

Steering clear of clinical theories in their quest to describe “the most
obvious features” allowed Orlinsky and Howard to see the therapy session with
fresh eyes and to think about it systematically and from multiple aspects. Con-
sequently, the TSR explores patients’ and therapists’ experiences during ses-
sions (a) in terms of a dialogue about topics that directly or indirectly express
the patient’s problematic concerns, (b) as a process of exchange in which
patients seek certain benefits from their therapist and receive those (or other)
benefits in varied measure, (c) as a relationship expressed in the manner that
patient and therapist interact with one another, (d) as an encounter capable
of evoking and transmuting the patient’s (and therapist’s) feelings, (e) as an
experience whose quality depends on the patient’s level of self-relatedness, and
through all these (f) as an emergent, jointly constructed “social act”1 that pro-
gresses sequentially over the course of the session toward its therapeutic goal.
The TSR was designed to allow patients and therapists to report separately
from their own perspectives on these multiple aspects of their sessions by using
numerous but easily answered scales—a task that both the patients and ther-
apists in their study found meaningful.
Through statistical analyses and interpretations of the data generated
with the TSR, Orlinsky and Howard established that it was both possible and
important to study the experiences of therapy as reported by patients and
therapists—the “psychological interior of psychotherapy”—and not just their
behaviors, seen from the limited perspective of external observers. This is
now taken for granted, but it was somewhat revolutionary at the time because
process researchers believed (naively) that reliance on audiotapes of sessions
would allow them to observe “what really happens in therapy.” The TSR also
informed the development of some nonparticipant process measures like the
Vanderbilt Psychotherapy Process Scale (VPPS), as acknowledged by Strupp,
who noted that “the VPPS . . . conception owes much to the pioneering
research of Orlinsky and Howard” (Suh, Strupp, & O’Malley, 1986, p. 286).
Using the TSR, data were collected on approximately 2,500 sessions from
patients and 1,500 sessions from therapists between 1965 and 1967, enabling
the investigators “to delineate the objective structure of its intersubjective real-
ity” (Orlinsky & Howard, 1986b, p. 486). Factor and cluster analyses indicated
the presence of 11 dimensions and four profiles or patterns of patient experi-
ence, which the investigators identified as helpful, stressful, dependent, and
counterdependent experiences (Orlinsky & Howard, 1975). The data for ther-
apists yielded 11 dimensions but only two patterns, which were identified as
helping experience and stressful experience.
1In the sense defined by George Herbert Mead (1954).

Perhaps the least appreciated and theoretically most important of the
findings were those of the five conjoint experience dimensions that were signifi-
cantly loaded by both patient and therapist dimensions. Conjoint experience
dimensions such as sympathetic warmth vs. conflictual erotization, therapeutic
alliance vs. defensive impasse, and productive rapport vs. unproductive contact
showed how patients’ and therapists’ experiences of the same therapy sessions
can be manifestly different and yet powerfully interconnected.
Studies based on the TSR generated a series of other publications dur-
ing the 1960s and 1970s, including the now classic article on “the good ther-
apy hour” (Orlinsky & Howard, 1967). In addition to being valuable for
researchers, this work can also assist therapists in connecting to the experi-
ences of clients and can specifically sharpen therapists’ focus on the great
variability in how clients assess the therapy process.
Patients’ and Therapists’ Experiences Between Sessions
Another example of Orlinsky’s interest in exploring obvious but excluded

aspects of therapy, and in devising innovative instruments to study them, is
the work on patients’ and therapists’ intersession experiences. It is common
knowledge that patients and therapists recall and make use of their experiences
of therapy in the intervals between sessions and imagine interacting with one
another. Recognizing the importance of these phenomena for therapy, Orlinsky
and his students developed parallel instruments called the Intersession
Experience Questionnaires (IEQ) for patients and therapists (Orlinsky, Geller,
Tarragona, & Farber, 1993).
The IEQ represents an attempt to understand how therapy “keeps work-
ing” between sessions, and it can be seen as complementing or expanding the
TSR. The relationships between patients’ in-session and intersession experi-
ences were initially explored with this instrument (Tarragona & Orlinsky,
1988), and research on the topic was recently renewed (Zeeck, Hartmann, &
Orlinsky, 2006). This work continues with large samples of intersession data
collected in Chicago and Freiburg (Germany) currently being analyzed by
Orlinsky and Hartmann.
Empirical Study of the Development of Psychotherapists
Traditionally, psychotherapy research has focused mainly on treatment

methods and on clients’ characteristics, in-session behaviors, and clinical out-
come, whereas the psychotherapist has largely remained terra incognita. This
aspect of therapy once more motivated Orlinsky to launch into a new area of
research, and in 1989 he played a major role in cofounding the SPR Collab-
orative Research Network (CRN) to conduct an international study of the

development of psychotherapists. Meeting intensively before and after SPR
conferences, a group of colleagues from different countries, professional back-
grounds, and theoretical orientations worked together to construct an instru-
ment with which they could learn more about how psychotherapists work and
develop over the course of their careers. Those who participated in these
meetings recall countless revisions of questions after long, sometimes heated
discussions, and then—after enjoying a fine meal together—when most went
to rest, Orlinsky worked during the night and arrived with new, improved
proposals the next morning. His commitment to thorough conceptual analy-
sis and empathy with those to be studied significantly shaped the Develop-
ment of Psychotherapists Common Core Questionnaire (DPCCQ).
The DPCCQ has been translated into 20 languages to date and has been
used in more than two dozen countries to collect reports about their work
experiences and professional development from nearly 9,000 psychotherapists.
Details of the instrument and its findings have been published in journals (e.g.,
Orlinsky, Botermans, & Rønnestad, 2001) and in the book by Orlinsky and
Rønnestad (2005), How Psychotherapists Develop: A Study of Therapeutic Work
and Professional Growth. Grounded inductively in descriptive ratings by ther-
apists of diverse professions and orientations, at all career levels and in many
countries, this work traced four patterns of practice—effective, challenging,
disengaged, and distressing—based on two factor-analytic dimensions of
therapist work experience, identified as healing involvement and stressful
involvement (resembling findings mentioned earlier based on use of the TSR
to examine individual therapy sessions). These practice patterns in turn were
differentially related to dimensions of current development (empirically iden-
tified as currently experienced growth and currently experienced depletion)
and to measures of overall career development. These and other findings were
integrated theoretically in a “cyclical-sequential model of psychotherapist
development” and applied practically to make empirically grounded recom-
mendations for clinical training, supervision, and therapeutic practice. Based
on this, Orlinsky and Rønnestad (2005) constructed normed self-monitoring
scales of work involvement and professional development for use by students,
supervisors, and practicing psychotherapists. These scales may be used for
many purposes, as described by Orlinsky and Rønnestad (2005).
Here, we would like to highlight the pragmatic purpose of having super-
visors and supervisees identify the eroding consequences of experiencing ther-
apeutic work as a stressful involvement, the elements of which are frequently
experiencing difficulties in practice, in-session feelings of anxiety or boredom,
and avoiding therapeutic engagement. Therapists and those responsible for
therapist training and practice should be aware of the potentially deleterious
effects of lack of work setting support and work satisfaction, and also the lim-
itations of a narrow range of case experience. Conversely, because breadth

and depth of case experience fuels overall career development and because
theoretical breadth predicts healing involvement, therapists should ensure
variety in their therapeutic work and seek theoretical inspiration from many
sources. Orlinsky and his CRN colleagues are continuing their international
study by expanding data collection in previously unstudied Western and
non-Western countries; examining the distinctive characteristics shared by
therapists of specific orientations (e.g., Elliott et al., 2003); and exploring
aspects of therapists’ personal lives, such as the nature and impact of their
religious background and experiences (e.g., Smith & Orlinsky, 2004). The
CRN project has become the largest study of psychotherapist development
and one of the longest-lasting research projects ever conducted in the field
of psychotherapy research.
Process–Outcome Research Reviews and Theoretical Contributions
David Orlinsky has written several major reviews of psychotherapy and

psychotherapy research. The stage for his integrative contributions was set as
early as 1972, when Ken Howard and he published a review of psychotherapy
research in the prestigious Annual Review of Psychology (Howard & Orlinsky,
1972). This was followed by chapters on process–outcome psychotherapy
research in four successive editions of the Handbook of Psychotherapy and
Behavior Change. In addition to providing an invaluable bibliographic resource
for researchers, work on these chapters led directly to the formulation of the
empirically grounded conception of process and outcome known as the generic
model of psychotherapy (Orlinsky & Howard, 1986a, 1987).
Drawing on knowledge from the social sciences in general, the generic
model distinguishes therapy process as a system of action that affects and is
affected by surrounding systems like patients’ and therapists’ personalities and
their social and cultural environments. Six facets of process are differentiated
on the basis of extant research: (a) the organizational aspect of therapy (thera-
peutic contract), (b) the technical aspects of therapy (therapeutic operations),
(c) the interpersonal aspects of therapy (therapeutic bond), (d) the intra-
personal aspects of therapy (participants’ self-relatedness), (e) clinical aspects
of therapy (in-session impacts), and (f) sequential aspects of process (temporal
patterns). The model provides a contextualized view of psychotherapy by delin-
eating the relation of therapeutic process both to antecedent conditions in the
psychological, cultural and social system environments (inputs) and to conse-
quent conditions in those environments (outputs), which include the psycho-
logical consequences of therapeutic process for patients (clinical outcome).
The findings of more than 50 years of psychotherapy process–outcome
research have been successfully synthesized in this framework (Orlinsky,
Rønnestad, & Willutzki, 2004). The model has generated a number of

empirical studies that also demonstrate its prospective utility (e.g., Kolden,
1991). The model also has served as a framework for integrating a variety of
clinical theories and treatment approaches to help students “learn from many
masters” (e.g. Orlinsky, 1994).
More recently, Orlinsky has worked to extend the generic model in ways
that clarify and differentiate the contextual domains in which outcome is
assessed (Orlinsky, 2004a, 2004b), that illuminate the widely accepted but
largely unexplained power of the therapeutic relationship to change the patient’s
life and personality (Orlinsky, in press), and that elucidate the spiritual aspect
of psychotherapeutic work.
Society for Psychotherapy Research
In addition to his research, Orlinsky has contributed much to psycho-

therapy research through his ongoing efforts to bring researchers together.
In 1968–1969, David Orlinsky and Ken Howard founded SPR to serve as an
open forum for all who are interested in the scientific study of psychotherapy.
David has elsewhere told how he and Ken were motivated to do this when they
were young researchers by being excluded in 1966 from attending a closed con-
ference on therapy research sponsored jointly by APA and the National Insti-
tute of Mental Health, even though it was held on their home campus at the
University of Chicago (Orlinsky, 1995). Ken Howard served SPR as its first
president and David served as its first president-elect; they drafted the soci-
ety’s constitution and bylaws; they organized and hosted SPR meetings from
1968 through 1971, in 1985, and again in 2000. Orlinsky also served as the
first president of the North American chapter of SPR; chaired the constitu-
tion and bylaws committee and the committee on international development;
cofounded the SPR CRN; and, most recently, led in creating the SPR inter-
est section on culture and psychotherapy. Nowhere is David Orlinsky’s drive
to make meaningful connections between ideas and people more evident than
in his efforts to establish, organize, and sustain SPR.
CONCLUSION
We can summarize what has been said about David Orlinsky by highlight-
ing some dominant characteristics of his work. One is a consistent focus on the
scientific study of subjective experience, rooted in his early interests in science
and poetry and brought to fruition by his undergraduate and graduate studies at
the University of Chicago. Another is his attention to the contextual embed-
dedness of experience—including the experience of psychotherapy—reflecting
his broad background in the social sciences and humanities. His interest in

the nature of personal relationships (in psychotherapy, in friendship, and in
love relationships) reflects early family experiences, as do his commitment to
collaborative research, his efforts to create and sustain personal communities
based on shared intellectual interest, and his inclination to find and study
phenomena that others tended to overlook. His efforts to construct systematic
conceptual models also subtly reflect his early family experience, as well as the
interdisciplinary knowledge and intellectual discipline acquired through his
long tenure at the University of Chicago.
In focusing on David’s scientific and professional contributions, we have
only been able to hint at some of his qualities as a person—his warmth, wit,
and welcoming manner; the care and commitment he shows towards friends;
the patience, intellectual stimulation, and support he extends to students and
colleagues. If one phrase can capture the spirit of a man, for David it would
probably be the words that E. M. Forster chose as the epigraph for his novel
Howards End: “Only connect.” Reflecting his background, values, and per-
sonality, David has sought to connect in many ways: to connect facts in ways
that produce knowledge; to connect concepts in ways that produce theory; to
connect and integrate different theoretical perspectives; and, not least, to
connect persons.
REFERENCES
Elliott, R., Orlinsky, D., Klein, M., Amer, M., & Partyka, R. (2003). Professional
characteristics of humanistic therapists: Analyses of the Collaborative Research
Network Sample. Person-Centered and Experiential Psychotherapies, 2, 188–203.
Geller, J. D., Norcross, J. C., & Orlinsky, D. E. (Eds.). (2005). The psychotherapist’s
own psychotherapy: Patient and clinician perspectives. New York, NY: Oxford
University Press.
Howard, K. I., & Orlinsky, D. E. (1972). Psychotherapeutic processes. Annual Review
of Psychology, 23, 615–668. doi:10.1146/annurev.ps.23.020172.003151
Kolden, G. G. (1991). The Generic Model of Psychotherapy: An empirical investi-
gation of process and outcome relationships. Psychotherapy Research, 1, 62–73.
doi:10.1080/10503309112331334071
Mead, G. H. (1934). Mind, self, and society from the perspective of a social behaviorist.
Chicago, IL: University of Chicago Press.
Orlinsky, D. E. (1994). Ansaetze zu einer wissenschaftlichen Integration psycho-
therapeutischer Behandlungsmethoden [Learning from many masters]. Psycho-
therapeut, 1, 2–9.
Orlinsky, D. E. (1995). The greying and greening of SPR: A personal memoir on
forming the Society for Psychotherapy Research. Psychotherapy Research, 5,
343–350.

Orlinsky, D. E. (2004a). Der menschliche Kontext von Psychotherapien, Teil 1 [The
human context of psychotherapy, part 1: Social and cultural contexts of psycho-
therapy]. Psychotherapeut, 49, 88–100. doi:10.1007/s00278-004-0360-7
Orlinsky, D. E. (2004b). Der menschliche Kontext von Psychotherapien, Teil 2 [The
human context of psychotherapy, part 2: The individual context of psycho-
therapy]. Psychotherapeut, 49, 161–181.
Orlinsky, D. E. (2005). Becoming and being a psychotherapist: A psychodynamic
memoir and meditation. Journal of Clinical Psychology/In Session, 61, 999–1007.
Orlinsky, D. E. (in press). Die psychotherapeutische Beziehung, Soziale Unter-
stützung und die Heilende Energie des Therapeuten: Eine Neo-Durkheim’sche
Perspektive [The therapeutic relationship, social support, and the psychothera-
pist’s healing energy: A neo-Durkheimian perspective]. In B. Röhrle & A.-R.
Laireiter (Eds.), Soziale Unterstützung und Psychotherapie. Tübingen, Germany:
dgvt-Verlag.
Orlinsky, D. E., Botermans, J.-F., & Rønnestad, M. H. (2001). Towards an empirically-
grounded model of psychotherapy Training: Five thousand therapists rate influ-
ences on their development. Australian Psychologist, 36, 139–148. doi:10.1080/
00050060108259646
Orlinsky, D. E., Geller, J., Tarragona, M., & Farber, B. (1993). Patients’ representa-
tions of psychotherapy: A new focus for psychodynamic research. Journal of Con-
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in
psychotherapy—noch einmal. In A. Bergin & S. Garfield (Eds.), Handbook of
psychotherapy and behavior change (4th ed., pp. 270–376). New York, NY: Wiley.
Orlinsky, D. E., & Howard, K. I. (1967). The good therapy hour: Experiential cor-
relates of patients’ and therapists’ evaluations of therapy sessions. Archives of
Orlinsky, D. E., & Howard, K. I. (1975). Varieties of psychotherapeutic experience:
Multivariate analyses of patients’ and therapists’ reports. New York, NY: Teach-
ers College Press.
Orlinsky, D. E., & Howard, K. I. (1978). The relation of process to outcome in psy-
chotherapy. In S. Garfield & A. Bergin (Eds.), Handbook of psychotherapy and
behavior change (2nd ed., pp. 283–329). New York, NY: Wiley.
Orlinsky, D. E., & Howard, K. I. (1986a). Process and outcome in psychotherapy. In
S. Garfield & A. Bergin (Eds.), Handbook of psychotherapy and behavior change
(3rd ed., pp. 311–381). New York, NY: Wiley.
Orlinsky, D. E., & Howard, K. I. (1986b). The psychological interior of psycho-
therapy: Explorations with the Therapy Session Reports. In L. Greenberg & W.
Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 477–501).
Orlinsky, D. E. & Howard, K. I. (1987). A generic model of psychotherapy. Journal
of Integrative and Eclectic Psychotherapy, 6, 1, 6–36.

Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists develop: A study of
therapeutic work and professional growth. Washington, DC: American Psycholog-
ical Association. doi:10.1037/11157-000
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of psychother-
apy process-outcome research: Continuity and change. In M. J. Lambert (Ed.),
Garfield and Bergin’s handbook of psychotherapy and behavior change (5th ed.,
Smith, D. P., & Orlinsky, D. E. (2004). Religious and spiritual experience among
psychotherapists. Psychotherapy: Theory, Research, Practice, Training, 41, 144–151.
Suh, C. S., Strupp, H. H., & O’Malley, S. S. (1986). The Vanderbilt process mea-
sures: The psychotherapy process scale (VPPS) and the negative indicators scale
(VNIS). In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process:
A research handbook (pp. 285–323). New York, NY: Guilford.
Tarragona, M., & Orlinsky, D. E. (1988, June). During and beyond the therapeutic hour:
An exploration of the relationship between patients’ experiences of therapy within and
between sessions. Paper presented at the 19th annual meeting of the Society for
Psychotherapy Research, Santa Fe, NM.
Zeeck, A., Hartmann, A., & Orlinsky, D. E. (2006). Internalization of the therapeu-
tic process: Differences between borderline and neurotic patients. Journal of Per-
sonality Disorders, 20, 22–41. doi:10.1521/pedi.2006.20.1.22

D. INTEGRATION OF
MULTIPLE VARIABLES
21
HORST KÄCHELE: BRINGING
RESEARCH, PRACTICE,
AND PEOPLE TOGETHER
BERNHARD STRAUSS
It is almost self-evident that the German-speaking countries have a pos-

itive tradition of psychoanalytic psychotherapy and psychodynamic psycho-
therapy research. Otto Fenichel (1930) was one of the first to document the
effectiveness of psychoanalysis in his systematic “Statistical Report About the
Therapeutic Work of the Berlin Psychoanalytic Institute Between 1920 and
1930.” More than 30 years later, an influential report by Annemarie Dührssen
(Dührssen & Jorswieck, 1965) indicated positive long-term effects of psycho-
analytic treatment in a follow-up study of 1,004 patients treated in Berlin. In
retrospect, this study has had tremendous influence on the political decisions
to include psychotherapeutic treatment as a standard benefit of both public
and private insurance in the German health system (Kächele, 2001). Today,
psychodynamic treatment (including long-term psychoanalysis) and cognitive
behavior therapy are standard inclusions covered by the insurance system.
It is not surprising that such a positive environment has favored many
activities of researchers in the field of psychotherapy in psychology and med-
icine. Today, there are many active research groups in international networks
distributed over the entire country. This was not always the case: During the
postwar decades German universities had only a few collaborations in
psychoanalysis and psychotherapy research.
247
Subsequently, the research group at Ulm, where Horst Kächele has spent
most of his professional life, holds specific importance among the German
research groups in at least two respects. One is the intensive and ongoing
effort to contribute to the development of psychoanalytic treatment based
upon theory, clinical work, and empirical research, and the other is the early
attempt of Horst Kächele and Helmut Thomä, the former head of the Depart-
ment of Psychotherapy, to bring researchers and research approaches from
around the world together through international collaboration and organiza-
tion, especially within the Society for Psychotherapy Research (SPR).
This chapter is primarily aimed at describing how Horst Kächele achieved
his two major contributions, namely, (a) advocating empirical process and out-
come research within psychoanalysis and (b) developing international collab-
orations in psychotherapy research and professional practice.
MAJOR CONTRIBUTIONS
Having served as the head of the Ulm Department of Psychotherapy and

Psychosomatic Medicine and as the chair of the Center for Psychotherapy
Research in Stuttgart, Horst Kächele has always regarded psychoanalytic
process research as his’s primary passion. His work using qualitative and quan-
titative approaches to the understanding of psychodynamic treatment has
been fundamental for the profile of the entire Ulm research group. His and
Helmut Thomä’s attempts to integrate these research findings into a teach-
able theory of psychoanalytic psychotherapy have been summarized in dif-
ferent editions of their textbook Psychoanalytic Practice (Thomä & Kächele,
1987, 1991; Kächele & Thomä, 1999). In addition to his work related to a
model of process research to describe psychoanalytic treatment, Kächele was
a very successful initiator and stimulator of research projects—in many spe-
cific fields of psychosomatic medicine and psychotherapy, motivating young
researchers to establish and to continue scientific work in these fields.
Horst Kächele always has been a cosmopolitan in the psychotherapeu-
tic world. Accordingly, he has been very active in trying to establish clinical
and research cooperation with South American and Eastern European coun-
tries, and he considers himself one of the godfathers of the Latin American
chapter of SPR.
EARLY BEGINNINGS
Born in 1944 in a peaceful Tyrolean village, where his father admin-

istered the production of motors for Heinkel airplanes until the end of
World War II, Horst Kächele grew up in Stuttgart. His father worked as a
248 BERNHARD STRAUSS

public attorney in the postwar denazification campaign. This second career
of his father’s probably had an impact on Kächele’s choice of his profes-
sion, which values empathy and social justice, and also on his continuous
political activities that aimed at preserving memories of the dark chapters
of German history (e.g., he was very active in a committee promoting a
memorial for the Oberer Kuhberg concentration camp in Ulm, situated
close to Kächele’s department).
A salient feature of his life trajectory was a rather early imprint from
meeting psychoanalysts of various convictions as a high school (gymnasium)
student in Stuttgart. His idea to move in the direction of psychoanalysis as a
career was set around the age of 17 or 18 because he thought that this profes-
sion could be a synthesis of art and science. However, a young man who
already knows at the age of 18 that he wants to become a psychoanalyst has
to suppress this drive for awhile. Horst Kächele decided to bridge the time
until the start of his psychoanalytical training with a medical education (at
the universities of Marburg, Leeds [UK], and Munich) instead of a psycholog-
ical one, because of his affinity for the natural sciences. He received his MD
in 1969 for a thesis titled “Psychogenic Death in the Medical Literature”
(Kächele, 1970). His doctoral dissertation was related to an issue thatin
psychoanalytic circles today would be called “conceptual research.” He was
screening the literature for the psychophysiological mechanisms involved, to
explain this surprisingly common phenomenon.
When he finished his doctoral thesis, he chose Ulm University for his
professional career. At that time, Ulm University was newly founded, and
the medical faculty had been assembled in light of a number of reformist
ideas, among them the inclusion of a department of psychosomatic medicine
(chaired by Thure von Uexküll, one of the most influential mentors of this
medical discipline in Germany) and a psychotherapy department led by
Helmut Thomä, who already was a very well-known psychoanalyst at this time.
Between 1970 and 1975, Horst Kächele obtained a German Research
Council–funded research position in Ulm. At the unusually young age of
33 he became Privatdozent following his postdoctoral lecture qualification
(including a thesis, on “Computer- assisted Content Analysis in Psycho-
analytic Process Research”). He was then appointed as an associate profes-
sor of psychotherapy, heading a section on psychoanalytic methodology for
the next 13 years at the Ulm Department of Psychotherapy. During this
time (1980–1989), his major achievements were to urge cooperation in cre-
ating a funded multidisciplinary research effort on the psychotherapeutic
process and later to establish the “Ulm Textbank,” together with the com-
puter scientist and later SPR president Erhard Mergenthaler. This database
enabled the administration and analysis of huge amounts of psychotherapy-
related transcripts.
HORST KÄCHELE 249

In 1990, Horst Kächele followed Helmut Thomä as the head of the
entire department that, a few years later, was combined with the Department
of Psychosomatic Medicine.
ACCOMPLISHMENTS
When Kächele was hired by Thomä at the psychotherapy department

of Ulm University, it was for working to resolve the very specific problem of
handling and analyzing tape recordings of psychotherapeutic sessions. Thomä
became his mentor from that moment—it is said that Thomä handed a can
opener to Kächele when he began to work to symbolize the wish that he
would succeed in opening the many “canned goods” he had collected!
The relationship between the two was always complementary, sometimes
controversial (especially when Thomä and Kächele talked about patients—
many colleagues might remember brilliant disputes) but mostly friendly,
and resulted in a large number of publications of which their textbook
on psychoanalysis (see Thomä & Kächele, 1987, 1991; Kächele & Thomä,
1999) undoubtedly is the most important. A highlight of their cooperation
was their joint receipt in 2002 of the Sigmund Freud Award from the City
of Vienna. Even today, the two have a very productive friendship, and their
collaboration is central to Kächele’s research contributions.
Research Studies
When Horst Kächele was president of the SPR, he presented a program-

matic presidential address that advocated for the intensive analysis of narra-
tives generated in psychotherapy using qualitative and quantitative measures.
His early clinical practice sharpened his view of salient research issues (e. g.,
the urgent need to overcome the “fairy-tale culture” of clinical reporting).
When the Ulm group began its systematic work on psychoanalytic
processes in the early seventies, it first focused on the extensive analysis of
single patient cases that were treated by H. Thomä. The rationale for inten-
sive case studies was to bridge the gap between the clinical and the scientific
approach and to keep qualitative and quantitative approaches combined.
Therefore, this strategy first involved investigation into a single case in which
narrative accounts of the therapists were available. Next, cases were aggre-
gated when the research team felt safe enough not to violate the specifics of
the single case:
We comprehend the transference neurosis as an interactional representa-
tion in the therapeutic relationship of the patient’s intrapsychic conflicts,
the concrete arrangement of which is a function of the analytic process.

This is unique for each dyad, and thus psychoanalysis can legitimately
be called a historical science; on the other hand, at a higher level of
abstraction it permits the identification of typical patterns of the course
of analysis. (Thomä & Kächele, 1987, p. 331)
Both Thomä and Kächele continually reflected on aspects of method-
ology and the philosophy of science related to psychoanalysis and intensively
discussed critical arguments against psychoanalytic theory (e.g., Grünbaum,
1984) by demonstrating the usefulness of empirical research methods to sup-
port the validity of psychodynamic constructs. A basic essay on the philoso-
phy of science in psychoanalysis from 1973 was recently reviewed and revised
(Kächele & Thomä, 1999).
The leading idea of the Ulm research program on psychoanalysis was to
use descriptive data of a different quality to examine clinical process hypothe-
ses. The basic methodological conception was inspired by Helen Sargent’s
(1961) recommendations for the Topeka Project, consisting of a four-level
approach; on each level, different methods with appropriate material repre-
senting different levels of conceptualization should be worked on:
I Clinical case study
II Systematic clinical descriptions
III Guided clinical judgment procedures
IV Computer-assisted and linguistic text analysis
The long-term goal of Kächele’s work has been to establish ways of
systematically describing the various aspects and dimensions of the psycho-
analytic processes. This has entailed the generation of general process hypothe-
ses as well as the specification of single-case process assumptions:
Specifying how a psychoanalytic process should unfold must go beyond
general clinical ideas by considering the kind of material brought forth
by each patient and the strategic interventions most appropriate to
achieving change in the dimensions of theoretical relevance specified for
each particular case. Although our approach excluded the use of non-
clinical measures to limit the intrusions on the clinical process, inde-
pendent psychometric pre-post outcome data were used to assess the
effectiveness of the psychoanalytic treatment, and have been published.
(Thomä & Kächele, 1997, p. 458)
The first case to be treated by such comprehensive clinical description,
the case of Christian Y, was a collaborative endeavour that included the
treating analyst, a second psychoanalyst, and a clinical psychologist, in a
group-discussion working style. Later, a similar description was prepared for
a second research case, that of Amalie X, which has become a specimen case
of psychoanalytical single-case research and still is the subject of intensive
research (Kächele et al., 2006): Amalie X (born 1939) suffered from body
HORST KÄCHELE 251

image difficulties and was in psychoanalytic treatment (517 sessions) during
the early 1970s with good results. Some years later she returned to her former
therapist for a short period of analytic therapy because of problems with her
lover, many years her junior. Twenty-five years later, her final separation from
this partner was causing her unbearable difficulties, and she consulted a
colleague for additional help.
The case of Amalie has been analyzed with a variety of objective and
standardized methods that have been described in a series of publications
(for a summary, see Kächele et al., 2006). The group studied (a) change of
emotional insight, (b) change of self-esteem, (c) types of subjective suffering,
(d) change in dreams, (e) the focal model of process assessed by the core con-
flictual relationship theme (CCRT) method, (f) breaks between sessions and
the analytic process, (g) the “unconscious plan” in terms of control-mastery
theory, and (h) psychoanalytic technique as assessed by the psychotherapy
process Q-sort method.
At the next level of data analysis, computer-aided text analyses were
used with the goal of extending the descriptive power of these observational
methods toward narrative efforts that would bring enriched meaning to the
lexical analyses from the textbank. The following list summarizes the single
approaches developed in the Ulm Textbank to analyse verbal material from
psychoanalysis and that have been comprehensively used in a variety of
studies: verbal activity, long-term transference trends, personal pronouns,
redundancy in patient’s and therapist’s language, classification of anxiety
themes, emotive aspects of therapeutic language, change of body concepts,
cognitive changes during psychoanalysis, changes of latent meaning struc-
tures, affective dictionary, parts of speech, and core conflictual words.
All results on psychoanalytic dialogues studied by these techniques under-
score the dyadic nature of the process. “Whatever microsystem is analyzed, one
finds dyadic dependencies and specifics within dyads. This has been one of the
reasons why the Ulm research paradigm has been so intrigued by the study of
singular cases” (Kächele, 1992b, p. 11). One of the fruits of Kächele’s initia-
tive that is closely linked with the Ulm Textbank is Erhard Mergenthaler’s
therapeutic cycle model describing the changing ratio between abstraction
and emotion and their connection during the psychotherapeutic process.
Implications of Kächele’s research on clinical practice can mostly be
seen as the continuous attempt to sensitize therapists for specific aspects or
variables of the therapeutic process, such as language, emotion, and conflict,
and to relate these variables to an operational model or system. Although
Horst Kächele was not directly involved in its development, it is not surpris-
ing that many of the authors of the operationalized psychodynamic diagnosis
system (OPD Working Group, 2008) have their professional origin in the
Ulm Department of Psychosomatic Medicine and Psychotherapy.

Stimulated by his visits to colleagues in the United States, such as Lester
Luborsky, Hans H. Strupp, or Hartvig Dahl, Horst Kächele imported a variety
of measures and approaches into German psychotherapy research, such as the
CCRT, the frames of mind-method, plan-analysis, and others. Together with
Klaus Grawe, he founded the PEP (Psychotherapeutische Einzelfall Prozess-
forschung, or, in English, Single-case Process Research [SPR]) project. The idea
of PEP was to collect a large number of process researchers who were experts
in a variety of measures/approaches and to initiate comparative research
related to just two single cases. The verbatim transcripts of two short-term
psychotherapies (one psychodynamic, the other one cognitive behavioral)
provided the basis for PEP. Kächele and Grawe succeeded in bringing more
than 40 different groups together, all working intensively with the material.
This project resulted in a large number of publications describing the process
of the two therapies on a linguistic level, using hermeneutic and specific
(process) measures such as SASB, the Vanderbilt Scales, the CCRT, and
many others (Kächele, 1992a).
OTHER CONTRIBUTIONS
Although process research, narration, and observation are Horst Kächele’s

primary interests, he also has initiated research in a wide variety of other fields
within the disciplines of psychotherapy and psychosomatic medicine. In his
function as the chair of the Stuttgart Center for Psychotherapy Research
(between 1988 and 2003), he was successful in getting a huge grant from
the German research ministry to run a 5-year research project consisting of
a multisite study of the effectiveness of an inpatient psychodynamic treat-
ment of eating disorders (e.g., Kächele, Kordy, & Richard, 2001). The study
investigated factors determining the length of treatment and the effect of
treatment duration on treatment outcome among patients with eating dis-
orders (anorexia and bulimia nervosa). It consisted of an observation of the
symptomatic status of 1,171 patients who were assessed for 2.5 years after their
admission to one of 43 participating hospitals. Treatment modalities, espe-
cially length and intensity, varied considerably between and within hospitals
but were related to patient characteristics to a very small degree. At 2.5-year
follow-up, 33% of patients with anorexia and 25% of the patients with
bulimia were symptom free. Length of treatment showed weak effects on out-
come and interacted with other relevant patient characteristics, whereas
treatment intensity was not clearly related to treatment outcome. This proj-
ect (TR-EAT) initiated a similar study on a European level and has con-
tributed to the implementation of patient-focused treatment research as one
major field of Horst Kächele’s team in Stuttgart, with Hans Kordy, another
HORST KÄCHELE 253

influential person in SPR, being the major representative (e.g. Puschner,
Kraft, Kächele, & Kordy, 2007).
Horst Kächele also stimulated research on the screening and utiliza-
tion of treatment in mothers suffering from postnatal depression (e.g., von
Ballestrem, Strauss, & Kächele, 2002), a study that was part of his major
research on perinatal medicine. In his Ulm group, a variety of well-funded
projects dealt with the determinants and consequences of premature birth
(e.g., Brisch et al., 2005; Buchheim et al., 1999). Research on attachment
was part of these projects and also figured in his work with adults (cf. Strauss,
Buchheim, & Kächele, 2002) and psychoanalytic single-case research (e.g.,
Buchheim & Kächele, 2003).
Among a wide variety of research fields (including music therapy, ethics
in psychotherapy, psycho-politics, neurobiology, and service and training
research; cf. http://www.la-vie-vecu.de), one important issue in Horst Kächele’s
work that deserves mention is psychooncology: Together with his colleagues
Volker Tschuschke and Norbert Grulke, he succeeded in establishing a
research group at Ulm University mainly dealing with research on coping and
determinants of survival in patients undergoing bone marrow transplantation
(e.g., Grulke, Bailer, Hertenstein et al., 2005).
INFLUENCES
Horst Kächele’s primary mentor was Helmut Thomä, but there were
several others who continuously worked with him and largely influenced his
theoretical thinking and the way he conceptualized psychotherapy research.
North American colleagues have already been mentioned (Luborsky, Strupp,
Orlinsky, Howard, Dahl, among others). Within the German-speaking world,
it was especially Adolf-Ernst Meyer, chair of the Department of Psycho-
somatic Medicine in Hamburg, with whom Horst was closely connected and
who supported his scientific ideas. Meyer’s conception of psychoanalytic
research was very similar to Horst Kächele’s, especially with respect to his
request that psychoanalytical concepts (and treatments) always should to be
empirically supported.
Conversely, Horst Kächele has mentored a variety of researchers in his
departments in Ulm and Stuttgart—Hans Kordy, Erhard Mergenthaler,
Michael Hölzer, Anna Buchheim, Reiner Dahlbender or Dan Pokorny, to
mention just a few—and he has significantly contributed to the development
of a well-functioning network of researchers and institutions active in psycho-
dynamic psychotherapy research inside and outside of Germany.
Kächele and Thomä attended several early SPR meetings in the United
States. After presenting at the first international conference on psychoanalytic

process research at Ulm University in 1985 (see Dahl, Kächele, & Thomä,
1988), Horst Kächele and his team hosted the 18th International Meeting of
the SPR in Ulm in 1987. This meeting was the first international SPR meet-
ing in a non-English-speaking country, and the first ever in Continental
Europe (many others, e.g., in Lyon, Geilo, Braga, Weimar, and Rome, were
to follow). The Ulm meeting opened the gate to SPR for many Europeans
(and people from other countries). Accordingly, this meeting also led to sev-
eral Europeans’ assuming responsible positions in SPR during the following
years. It is not surprising that Horst Kächele himself became the first Euro-
pean to be president of SPR. Several other Europeans, namely, Klaus Grawe,
Franz Caspar, Erhard Mergenthaler, and the author of this chapter, were able
to follow him.
CONCLUSION
Although close to retirement, Horst Kächele is still a very active

researcher, and he is still pursuing his idea of bringing psychoanalytical
practice and empirical research more closely together. In one of his recent
articles (Kächele et al., 2006) he summarized this work:
We say this in order to encourage other psychoanalysts to open the privacy
of their clinical work in the endeavour to improve clinical work by allow-
ing others in the scientific community to carefully scrutinize their work.
For this purpose, we recommend the training of researchers who are also
trained as clinicians, and the training of clinicians who are also trained
as researchers, so that they may learn to identify with both the clinical
and research tasks. (p. 824)
Although Horst Kächele also has actively participated in mainstream

psychotherapy research, as the variety of his projects in Ulm and Stuttgart
reflects, his legacy will be predominantly his specific efforts and approaches
to validate the process of psychoanalytic treatment. Horst Kächele’s major
interest was always directed to the empirically based development of psycho-
analytic theory that can be used by practicing clinicians. This has found its
condensation in his three-volume textbook Psychoanalytic Practice. This text-
book, which was published in a German second edition in 1996, has meanwhile
been translated into 11 languages (from Armenian to English to Spanish).
The numerous translations of this textbook reflect Horst Kächele’s ability to
bring the psychotherapy world together.
Perhaps it was two specific traits of Horst Kächele that made an extra-
ordinary psychotherapy researcher out of him. One is his ability to daydream.
He once described himself as a daydreamer in the sense of Ernst Bloch, who
HORST KÄCHELE 255

conceptualized daydreaming as the anticipation of imagination instead of a
regression to the past. Daydreams have undoubtedly quickened Horst Kächele’s
scientific imagination.
The other trait is described in an unpublished virtual dialogue with his
mentor Helmut Thomä. In this dialogue, Horst Kächele cites himself with the
statement: “Not to be counted among the conformists is the precondition of
creative beginning for me. This is always connected with the risk of a failure!”
REFERENCES
Brisch, K., Bechinger, D., Betzler, S., Heinemann, H., Kächele, H., Pohlandt, F.,
. . . Buchheim, A. (2005). Attachment quality in very low birthweight premature
infants in relation to maternal representations and neurological development.
Parenting: Science and Practice, 5, 311–331. doi:10.1207/s15327922par0504_1
Buchheim, A., Brisch, K. H., & Kächele, H. (1999). Clinical significance of attachment
research for the premature infant group: An overview of most recent research.
Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 27, 125–138.
Buchheim, A., & Kächele, H. (2003). Adult attachment interview and psychoanalytic
perspective: A single case study. Psychoanalytic Inquiry, 23, 81–101. doi:10.1080/
07351692309349027
Dahl, H., Kächele, H., & Thomä, H. (Eds.). (1988). Psychoanalytic process research
strategies. Berlin, Germany: Springer.
Dührssen, A. M., & Jorswieck, E. (1965). Eine empirisch-statistische Untersuchung zur
Leistungsfähigkeit psychoanalytischer Behandlung [An empirical statistical study
on the effectiveness of psychoanalytic long-term treatment]. Der Nervenarzt, 36,
166–169.
Fenichel, O. (1930). Statistischer Bericht über die therapeutische Tätigkeit 1920–1930.
[Statistical report about therapeutic work 1920-1930] In S. Radó, O. Fenichel,
& C. Müller-Braunschweig (Eds.), Zehn Jahre Berliner Psychoanalytisches Institut
(pp. 13–19). Vienna, Austria: Int. Psychoanalytischer Verlag.
Grulke, N., Bailer, H., Hartenstein, B., Kächele, H., Arnold, B., Tschuschke, V., &
Heimpel, H. (2005). Coping and survival in patients with leukaemia undergoing
allogeneic bone marrow transplantation: Long-term follow-up of a prospective
study. Journal of Psychosomatic Research, 59, 337–346.
Grünbaum, A. (1984). The foundations of psychoanalysis. Berkeley: University of
California Press.
Kächele. H. (1970). Der Begriff “psychogener Tod” in der medizinischen Literatur
[The term “psychogenic death” in the medical literature]. Zeitschrift Psychosoma-
tische Medizin und Psychoanalyse, 16, 105–129/ 202–223.
Kächele, H. (1992a). Une nouvelle perspective de recherche en psychotherapie :
Le projet PEP. Psychothérapies 2, 73–77.

Kächele, H. (1992b). Narration and observation in psychotherapy research. Reporting
on a 20-year-long journey from qualitative case reports to quantitative studies on
the psychoanalytic process. Psychotherapy Research, 2, 1–15.
Kächele, H. (2001). Psychotherapeutische Forschung über ein Jahrhundert [Psycho-
therapy research over one century]. In H. C. Deter (Ed.), Psychosomatik am
Beginn des 21. Jahrhunderts [Psychosomatics in the beginning of the 21st century]
(pp. 39–46). Bern, Switzerland: Huber.
Kächele, H., Albani, C., Buchheim, A., Hölzer, M., Hohage, R., Jiménez, J. P.,
. . . Thomä, H. (2006). The German specimen case Amalia X: Empirical
studies. International Journal of Psycho-Analysis, 87, 809–826. doi:10.1516/
17NN-M9HJ-U25A-YUU5
Kächele, H., Kordy, H., & Richard, M. (2001). Therapy amount and outcome of
inpatient psychodynamic treatment of eating disorders in Germany: Data from
a multicenter study. Psychotherapy Research, 11, 239–257.
Kächele, H., & Thomä, H. (1999). Textbook of psychoanalytic therapy: Vol. III. Research.
http://sip.medizin.uni-ulm.de.
OPD working group (2008). Operationalized psychodynamic diagnosis (OPD-2). Bern,
Switzerland: Huber.
Puschner, B., Kraft, S., Kächele, H., & Kordy, H. (2007). Course of improvement dur-
ing two years in psychoanalytic and psychodynamic outpatient psychotherapy.
Psychology and Psychotherapy, 80, 51–68.
Sargent, H. D. (1961). Intrapsychic change: Methodological problems in psycho-
therapy research. Psychiatry, 24, 93–108.
Sargent, H. D., Horwitz, L., Wallerstein, R. S., & Appelbaum, A. (1968). Prediction in
psychotherapy research. Method for the transformation of clinical judgments into testable
hypothesis. New York, NY: International Universities Press.
Strauss, B., Buchheim, A., & Kächele, H. (Eds) (2002) Klinische Bindungsforschung
[Clinical attachment research]. Stuttgart, Germany: Schattauer.
Thomä, H., & Kächele, H. (1987). Psychoanalytic Practice. Vol.1: Principles. Berlin,
Springer.
Thomä, H., & Kächele, H. (1991). Psychoanalytic Practice. Vol.2: Clinical Studies.
Berlin, Germany: Springer.
von Ballestrem, C.-L., Strauss, M., & Kächele, H. (2002). Screening and utilization
of treatment in mothers with postnatal depression. In D. Ebert, K. P. Ebmeier,
& W. P. Kaschka (Eds.), Perspectives in affective disorders (pp. 25–34). Basel,
Switzerland: Karger. doi:10.1159/000066874
HORST KÄCHELE 257

22
ENRICO JONES:
APPRECIATING COMPLEXITY
TAI KATZENSTEIN, PETER FONAGY, AND J. STUART ABLON
Enrico Jones had a unique capacity, both professionally and personally,

for weaving multiple ideas, roles, and worlds together synergistically. As a
psychotherapy researcher and practicing psychoanalyst, Enrico was commit-
ted to avoiding oversimplification, and that commitment laid the groundwork
for some of his most outstanding achievements. He examined the psycho-
therapeutic and psychoanalytic treatment process in a way that allowed for the
richness and depth of true clinical complexity, while holding firmly to the
importance of empirical methodology as the mode for doing so.
MAJOR CONTRIBUTIONS
Enrico Jones’s considerable and multifaceted scientific contributions

stemmed from his attention to the social factors underlying both individual dif-
ferences and psychotherapy, as well as his focus on elucidating key elements of
psychotherapeutic process. In his efforts to identify sources of therapeutic action,
Jones created his empirically derived instrument, the Psychotherapy Process
Q-set (PQS). He also generated interaction structure theory, a theoretical and
empirical model, to better understand the mutative elements in psychotherapy.
259
In the late 1970s, Jones’s research focused on the psychological aspects
of race. He actively challenged racial stereotypes present in the literature. He
insisted that psychologists not accept simple answers. He warned against the
dangers inherent in regarding African Americans as a homogeneous group.
In keeping with the complex and subtle thinking for which he was so widely
respected, he voiced his reservations about the construction of ethnically spe-
cific norms of measurement. On the one hand, culture-specific measures
acknowledged a pluralism that had previously been disregarded. On the other
hand, Jones believed that these measures could themselves strike an exclu-
sionary note (by upholding a static view of society).
Enrico Jones was one of the earliest researchers to examine race and
psychotherapy systematically. In a brief and wonderfully cogent critique of
the field in the late 1980s, he argued that race was the wrong level of concep-
tualization for the individual differences among therapists (Jones, 1985). Pre-
saging some of the most salient themes to emerge in discussions about cultural
competence, Jones wrote succinctly: “The question is not how to treat the
black client but how to treat this black client” (p. 175). Jones’s emphasis on
the individuality of the patient and of each therapy relationship became cen-
tral to the second part of his career.
During the 1980s, Jones developed the PQS. His programmatic line of
research using this measure established him as a leading psychotherapy process
researcher. Whereas many researchers were pursuing the question of whether
therapy worked, Jones found the question of how therapy worked more com-
pelling. To this day, many regard the PQS as one of the most comprehensive
and clinically relevant empirical measures of psychotherapy process.
Jones’s research on psychotherapy process culminated in the publica-
tion of his book, Therapeutic Action: A Guide to Psychoanalytic Theory (Jones,
2000). This book details a conceptualization of therapeutic action that Jones
termed repetitive interaction structures. His interaction structure theory pro-
vides an empirical method with which to deconstruct not only the essence of
the therapy relationship but also the directions of influence that operate
between patient and clinician. Jones’s model of therapeutic action uses both
a methodological paradigm and a theoretical frame to answer one of the field’s
most important questions: What is it about the nature of the therapy relation-
ship that either facilitates or hinders change?
BEGINNINGS
Enrico Edison Jones was born in Munich, Germany, on November 25,

1947. Enrico’s father was African American and served as a master sergeant
in the U.S. Army. Enrico’s mother was born in Germany and worked as an
260 KATZENSTEIN, FONAGY, AND ABLON

early-childhood educator. Enrico’s parents met and fell in love when his father
was deployed to Germany during World War II. He spent his early childhood
living on military bases in Germany with his four siblings and parents. Ger-
man was his first language. When Enrico was 2 years old, his family moved to
the United States and eventually settled in Rochester, New York (after pass-
ing through Maine, New Jersey, Camp Kilmer, and Fort Dix). It is evident,
even in this brief snapshot of Jones’s early life, that the seeds of his unique
capacity to bridge complexities were planted early as he negotiated the chal-
lenges of growing up as an African American in postwar Germany, on two dif-
ferent continents, and in two different societies. The opportunities and
challenges that Jones no doubt encountered along the way played an impor-
tant role in shaping his thoughts about race, psychology, and relationships.
Jones was recruited from his Catholic high school as a National Merit
Scholar to attend Harvard. While he was growing up, his mother encouraged
him to follow in the steps of her father, a well-known and widely respected
physician. While Jones considered the option of pursuing medical school in
his early college years, he ultimately decided to major in history. During this
period, he attended a series of lectures delivered by Erik Erikson. He was
intrigued by Erikson’s developmental theory because of its attention to change
across time. This exposure formed an important bridge between the world of
psychology and Enrico’s interest in history (in which actors and narratives
also figure prominently).
In 1969, Jones graduated cum laude from Harvard. That same year, he
decided to pursue psychology in graduate school. He earned his PhD from
Berkeley in 1974 after completing his predoctoral internship at Mount Zion
Hospital. He joined the faculty directly out of graduate school. This rare
occurrence (the department did not typically hire from within) reflected the
high esteem in which Jones was held as a researcher, teacher, and intellectual.
He rose quickly through the ranks to full professor.
In 1981, Jones spent a sabbatical year in Paris as a member of the Centre
National de la Recherche Scientifique. This year marked an important shift in
the direction of his interests. Prior to his sabbatical, Jones’s line of research
had been in the field of ethnic minority health. In the years following his
return from sabbatical, he became intrigued by psychoanalysis from both
research and clinical perspectives. This new interest, combined with a long-
held interest in studying psychotherapy, formed the foundation for the pro-
grammatic line of research that dominated the second phase of his career.
Displaying his remarkable talent for fully living both parts of the
hyphenated identity of scientist–practitioner, in addition to holding an aca-
demic appointment as full professor at Berkeley, Jones maintained an active
clinical practice from 1982 onward. He completed psychoanalytic training at
the San Francisco Psychoanalytic Institute in 1992. Jones also held clinical
ENRICO JONES 261

appointments at the San Francisco Psychoanalytic Institute (1997–2000);
the Department of Psychiatry and Langley Porter Psychiatric Institute, Uni-
versity of California–San Francisco (1982–1996); and Mount Zion Hospital
(1976–1994).
ACCOMPLISHMENTS
Enrico Jones dedicated his research career to the following four domains
(listed chronologically in the order in which they emerged): (a) social aspects
of individual differences; (b) social factors in psychotherapy; (c) the study of
the psychotherapy process using the PQS; and (d) interaction structures and
therapeutic action.
Social Aspects of Individual Differences
Enrico Jones’s research on the psychological aspects of race revealed

that much of what psychologists were saying revolved around simplistic,
untenable assumptions with disturbingly little validity. In an early paper
(Jones, 1978a), Enrico challenged the racial stereotype propagated in the psy-
chological literature of the period, namely, that blacks showed estrangement,
distancing, or mistrust of society (“marks of past oppression”). Jones and
Zoppel (1979) demonstrated that dichotomies such as internal and external
locus of control did not translate cross-culturally or for different samples of
the same population within the United States. Jones’s pioneering work in the
area of ethnic minority mental health culminated with the publication of
the classic text Minority Mental Health (Jones & Korchin, 1982). This volume
provided the field with a comprehensive theoretical and empirical overview
of minority group differences in attitudes toward mental health, assessment
of symptoms, and therapeutic intervention.
Social Factors in Psychotherapy
In its early days, the Berkeley Psychotherapy Research Project, which

Enrico Jones founded, focused on the impact of demographic and social vari-
ables on psychotherapy. Jones was particularly interested in the effect on out-
come of the patient–therapist match. In one study, White therapists rated
both their Black and White—but particularly their Black—clients as psycho-
logically more impaired than did Black therapists (Jones, 1982). Jones
demonstrated that a substantial number of Black clients (50%) failed to
return to their therapist after an initial consultation. Many of his writings in
the 1970s addressed a cohort of clinicians who did not systematically think

about race. Jones contributed the idea that Black clients’ discussion of race
with their white therapists was not resistance, and that the liberal pretence
of “color blindness” was actually a denial of the uniqueness of the individual
(points that, on account of writings like Enrico Jones’s, are now assumed in
the provision of culturally competent care).
Yet, once again, Jones found that the simple view fit poorly with the
data. The Berkeley Psychotherapy Research Project found race to be a weak
predictor of patient outcome (Jones, 1978b, 1982; Jones & Zoppel, 1982).
The complex answer was that African and European American patients in
psychotherapy were more alike than different (Jones, 1982). Furthermore,
ethnic matching did not in and of itself affect the quality of the therapeutic
alliance. For Jones, the answer to this conundrum lay in the importance of
fully and thoroughly appreciating an individual’s subjectivity. Jones believed
that the way the field of psychology operationalized race was problematically
ambiguous and nonspecific. His focus on subjectivity and his finding that the
quality of the therapy alliance was not related to ethnic match led him down
a new and fruitful research path.
The Study of Psychotherapy and the Q-Set
During the 1980s, Enrico Jones responded to the field’s need for quan-
titative methods that preserved the depth and complexity of clinical material
while conforming to the requirements of empirical science. In an effort to
address this need, Jones spent more than a decade pioneering and developing
the PQS; Jones, 2000). The Q-set instructs coders to sort its 100 items accord-
ing to a normal distribution in terms of how well they describe a therapy session.
The items concern (a) patients’ attitudes, behavior, and experience; (b) thera-
pists’ actions and attitudes; and (c) the nature of the interaction of the dyad. The
Q-set is designed to provide a basic language for the description and classifica-
tion of treatment processes in a form suitable for quantitative analysis. This
instrument captures the uniqueness of each treatment hour while also per-
mitting the assessment of the similarities or dissimilarities between hours and
patients. (See Jones, 2000, for a more detailed discussion of the instrument
and its psychometric properties.)
The PQS has been used reliably for both group comparison and inten-
sive single-case designs. It has been applied to study treatments as diverse as
psychoanalysis, long- and short-term psychodynamic psychotherapy, cogni-
tive behavior therapy (CBT), interpersonal therapy, rational emotive ther-
apy, and gestalt therapy. The Q-set has also been used by panels of experts
from different theoretical orientations to construct prototypes of ideal treat-
ment hours instantiating their respective orientations. Use of the Q-set in
this way (referred to as prototype methodology) facilitates examining differences
ENRICO JONES 263

between what clinicians and patients actually do in treatment and what
experts and theories stipulate dyads should ideally be doing.
Using this measure, Jones and his colleagues contributed a series of
remarkable findings to the psychotherapy process and outcome literature. In
early studies, the Q-set demonstrated its value by empirically grounding com-
monly held clinical observations. For instance, one study (Jones, Cumming,
& Horowitz, 1988) empirically substantiated the clinical claim that tech-
nique must be adjusted to the severity of presentation. In this study, patients
with milder posttraumatic stress responses and pathological grief were
observed to do relatively well when their memories were linked with current
experience, their views of themselves were examined in relation to others,
and they were exposed to transference interpretations. By contrast, those who
suffered greater psychological distress did best when their therapist was more
reassuring, offered advice about reality-based problems, and provided feed-
back about the patient’s defenses. These findings, which make intuitive clin-
ical sense, are not in and of themselves surprising. What is remarkable,
however, is that they were demonstrated in an empirical study. The Q-set’s
capacity to tap a range of therapy techniques in a way that is highly relevant
to one’s work as a clinician is one of its unique and striking characteristics.
In several other studies, Enrico Jones applied the PQS empirically to
capture subtle therapeutic shifts in the treatment process. In one study (Jones
& Windholz, 1990), improvements were reflected in a shift from intellectu-
alization and rationalization to seeking separation and increased access to the
patient’s thoughts and feelings. In another study (Jones, Parke, & Pulos, 1992),
Jones and his colleagues determined that patients who experienced clinically
significant changes manifested a gradual shift from external reality-oriented
constructions of their difficulties to an emphasis on an inner self-reflective
orientation.
In a unique and complex article (Jones, Ghannam, Nigg, & Dyer, 1993),
Jones and his colleagues analyzed a two-and-a-half-year, twice-weekly, video-
taped psychodynamic psychotherapeutic treatment of a depressed woman.
They coded 53 hours of treatment and then identified four patterns (using
factor analysis) characterizing the nature of the patient’s and therapist’s inter-
actions: (a) the therapist was accepting/neutral (i.e., conveyed a sense of
nonjudgmental acceptance); (b) the therapist was interactive (didactic, chal-
lenged the patient’s views, was tactless); (c) the therapist used psycho-
dynamic technique (e.g., interpreted warded-off/unconscious wishes); and
(d) the patient experienced dysphoric affect (e.g., patient felt sad/depressed,
anxious/tense). Jones innovatively applied time series methodology (later a
central component of his methodological paradigm for examining the inter-
action patterns between patients and clinicians) to identify the regular co-
occurrences as well as the lag effects between therapist and patient behavior.

He found that the patient’s dysphoric affect regularly triggered high levels of
acceptance and neutrality in the therapist. Interestingly, the therapist’s sup-
portive stance and reassurance triggered the patient’s dysphoric affect. Jones
identified a large number of bidirectional effects. For example, the therapist’s
interactive and somewhat controlling behavior was triggered by and, in turn,
triggered the patient’s dysphoric affect.
A powerful feature of the PQS is that it can be applied to study psycho-
therapeutic treatments across a broad range of theoretical perspectives. In
a 1993 article with Steven Pulos, Jones reported that coders could use the PQS
to distinguish psychodynamic from CBT. The process–outcome results sug-
gested that in the 30 brief psychodynamic interventions, the score on the
Psychodynamic factor strongly related to outcome. That is, the more psycho-
dynamic process fostered, the better the outcome. Interestingly, this was not
the case for CBT. The factor labeled CBT Technique did not relate to out-
come for the 32 CBT treatments. Also, the higher the scores on the factor
labeled Negative Affect, the better the outcome in the case of psychodynamic
therapy. The opposite relationship held for CBT, which emphasizes regulation
and control of negative affect. Strikingly, in the CBT treatments, improve-
ment was associated with higher scores on the psychodynamic factor.
These findings might suggest that the mode of action in CBT has
more in common with psychodynamic processes than has traditionally been
assumed. But this would have been a simplification. Jones realized that there
was a weakness in this study: Both the Psychodynamic and the Cognitive
Behavioral factors were empirically derived and confounded with the material
they were supposed to evaluate. In a programmatic line of work conducted
with Stuart Ablon (Ablon & Jones, 1998, 1999, 2002), Jones used indepen-
dent experts to define prototypes of CBT and psychodynamic therapy using
the PQS. The degree to which treatments adhered to these theoretically
derived prototypes was then measured and correlated with outcome.
The Q-prototypes were applied to two archived treatment samples of
psychodynamic treatments (N = 30 and N = 38). Interestingly, in these data
sets, psychodynamic therapy correlated with both the psychodynamic and the
CBT prototypes, whereas CBT was only related to the CBT prototype. Sim-
ilarity to the psychodynamic prototype predicted outcome in one of the two
psychodynamic samples and the CBT sample. In this study, the CBT proto-
type was not significantly correlated with positive outcome (Ablon & Jones,
1998). The same technique was used to reanalyze tapes from the National
Institute of Mental Health Treatment of Depression Collaborative Research
Program. In this series of studies, both interpersonal psychotherapy and CBT
sessions adhered most strongly to the ideal prototype of CBT. Positive out-
come was associated with adherence to the CBT prototype (Ablon & Jones,
2002). The study shows just how misleading “brand-name” therapy can be; in
ENRICO JONES 265

particular, interpersonal psychotherapy was demonstrated in actual practice to
be startlingly similar to CBT.
The results of this programmatic line of research contain a warning
about the risks of oversimplification. Awarding the status of empirically sup-
ported treatments to particular brands of therapy without actually studying
the contents of these brands is equivalent to the Food and Drug Administra-
tion approving the trade name of a drug without concerning itself with the
generic substance on which it is based (Ablon & Jones, 2002). Ablon and
Jones powerfully reminded us of this point in a 1999 article in which they
demonstrated that for both interpersonal therapy and CBT, the process cor-
relates of outcome at the individual item level were neither technique- nor
orientation specific but patient-related.
Interaction Structures
Enrico Jones’s psychotherapy process research culminated in the publi-

cation of his book Therapeutic Action (2000). Here, Jones advanced a method-
ological and theoretical paradigm for examining the way in which relationship
representational structures could be observed in the therapeutic dyad and
linked to treatment outcome. Jones defined interaction structures as the repet-
itive, mutually influencing patterns that emerge over time when patients and
therapists engage in psychotherapy. According to Jones, interaction structures
were the major source of therapeutic action in psychodynamic/analytic treat-
ments. He stipulated that the repetitive, slow-to-change two-person patterns
comprising interaction structures reflected the psychological architecture
(e.g., character structure/personality and defenses/coping mechanisms) of
both clinicians and patients. Interaction structures were, therefore, highly
specific to the dyad in which they emerged. Instead of talking about individ-
uals, Jones (2000) required that we have a language describing the dyad and
its patterned interactions, again foreshadowing the field’s relatively recent
focus on intersubjectivity.
Jones’s interaction structure theory brings together the polarities of
insight and relationship. According to this theory, neither insight nor relation-
ship alone brings about change. Instead, change is facilitated by the mutual
exploration and shared understandings of patterns in the therapy relation-
ship. Jones (2000) wrote: “Therapeutic action is located in the experience,
recognition, and understanding by patient and therapist of these repetitive
interactions” (p. 4). It is through interaction with the patient that the ther-
apist tries to understand the patient’s mind and the patient endeavors to
understand his or her self. Through identifying the recurring themes in the
way therapist and patient interact, the psychological structure that motivates
both patient and therapist is thrown into relief.

Interaction structure is a bridging concept. It is also a construct that is
open to empirical scrutiny through sophisticated statistical analyses of PQS
ratings using factor analysis and time series analysis. The grouping of these
three methodologies—the PQS, factor analysis, and time series analysis—into
one unified paradigm reflected Jones’s overarching view that psychotherapy
process of all orientations, including longer term psychodynamic treatment,
could be examined in a clinically relevant and methodologically rigorous way.
OTHER CONTRIBUTIONS
Enrico Jones was the first African American professor in the psychology
department at Berkeley. Over the course of his career, he assumed a major
leadership role in the education and training of ethnic minority students. He
received the Kenneth and Mamie Clark Award for Outstanding Contribu-
tions to the Professional Development of Ethnic Minority Students. Jones
also served on the editorial boards of several organizations, including the Jour-
nal of Consulting and Clinical Psychology, the Journal of the American Psycho-
analytic Association, the International Journal of Psychoanalysis, and Psychological
Issues. He was a member of the Society for Psychotherapy Research, the Inter-
national Psychoanalytic Association, and the board for the Scientific Affairs
of the American Psychoanalytic Association. He enjoyed a number of fruitful
intellectual collaborations with both mentors and students (Robert Wallerstein,
Sheldon Korchin, Jack Block, and Stuart Ablon).
CONCLUSION
A central theme throughout this chapter has been Enrico Jones’s com-
mitment to avoiding oversimplification. Yet, ultimately, his achievement was
that of simplicity. He made the complexities of psychotherapeutic process,
including psychoanalytic thought and technique, understandable and acces-
sible. He mastered the dialectic of not succumbing to illusions generated by
reductionism and simplification, while avoiding the trap of creating mystique
and religion where the innocent questions can no longer be asked and the
truth is buried under multiple layers of false sophistication.
Enrico Jones’s legacies are considerable and multifaceted. His creation
and application of the Psychotherapy Process Q-set originated in his strong
belief that both process and outcome needed to be investigated in order to
understand why certain treatments worked and certain others failed.
Jones’s commitment to identifying and examining the processes that were
actually (as opposed to theoretically) unfolding and facilitating change in
treatment has laid important groundwork for the field’s newfound interest
ENRICO JONES 267

in identifying change processes. His inner conviction that it was possible
to study psychodynamic and psychoanalytic treatments, even in an era in
which funding from traditional agencies was draining away, communicates
an important message to young researchers about the value of following
what is most compelling, even when the logistical and external variables are
formidable.
Looking back at Enrico Jones’s 25 years of research, the tragedy of his pre-
mature death is felt deeply and sharply. It is evident that he could have con-
tinued and needed to continue for at least another quarter of a century to fulfill
his mission. Those who knew Enrico and his work can take some solace in the
realization that his work lives on in the current studies that use the measure
he created and in the breadth and depth of his students’ and colleagues’ ongo-
ing work, as well as in the continued efforts of the Research Committee of the
International Psychoanalytic Association and the Psychotherapy Research
Group at Massachusetts General Hospital.
REFERENCES
Ablon, J. S., & Jones, E. E. (1998). How expert clinicians’ prototypes of an ideal
treatment correlate with outcome in psychodynamic and cognitive-behavior
therapy. Psychotherapy Research, 8, 71–83. doi:10.1093/ptr/8.1.71
Ablon, J. S., & Jones, E. E. (1999). Psychotherapy process in the National Institute
of Mental Health Treatment of Depression Collaborative Research Program.
006X.67.1.64
Ablon, J. S., & Jones, E. E. (2002). Validity of controlled clinical trials of psychother-
apy: findings from the NIMH Treatment of Depression Collaborative Research
Program. American Journal of Psychiatry, 159, 775–783. doi:10.1176/appi.ajp.
159.5.775
Jones, E. E. (1978a). Black–White personality differences: Another look. Journal of
Personality Assessment, 42, 244–252.
Jones, E. E. (1978b). Effects of race on psychotherapy process and outcome: An
exploratory investigation. Psychotherapy: Theory, Research and Practice, 15,
226–236.
Jones, E. E. (1982). Psychotherapists’ impressions of treatment outcome as a function
of race. Journal of Clinical Psychology, 38, 722–731.
Jones, E. E. (1985). Psychotherapy and counseling with Black clients. In P. Pedersen
(Ed.), Handbook of cross- cultural counseling and therapy (pp. 173–179). Westport,
CT: Greenwood Press.
Jones, E. E. (2000). Therapeutic action: A guide to psychoanalytic therapy. Northvale,
NJ: Jason Aronson, Inc.

Jones, E. E., Cumming, J. D., & Horowitz, M. J. (1988). Another look at the non-
specific hypothesis of therapeutic effectiveness. Journal of Consulting and Clinical
Psychology, 56, 48–55. doi:10.1037/0022-006X.56.1.48
Jones, E. E., Ghannam, J., Nigg, J. T., & Dyer, J. F. (1993). A paradigm for single-case
research: the time series study of a long-term psychotherapy for depression.
006X.61.3.381
Jones, E. E., & Korchin, S. J. (Eds.). (1982). Minority mental health. New York, NY:
Praeger.
Jones, E. E., Parke, L. A., & Pulos, S. M. (1992). How therapy is conducted in the
private consulting room: A multidimensional description of brief psychodynamic
treatments. Psychotherapy Research, 2, 16–30.
Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic and
cognitive behavioral therapies. Journal of Consulting and Clinical Psychology, 61,
306–316. doi:10.1037/0022-006X.61.2.306
Jones, E. E., & Windholz, M. (1990). The psychoanalytic case study: Toward a
method for systematic inquiry. Journal of the American Psychoanalytic Association,
38, 985–1015. doi:10.1177/000306519003800405
Jones, E. E., & Zoppel, C. L. (1979). Personality differences among Blacks in Jamaica
and the United States. Journal of Cross-Cultural Psychology, 10, 435–456. doi:10.
1177/0022022179104003
Jones, E. E., & Zoppel, C. L. (1982). Impact of client and therapist gender on psycho-
therapy process and outcome. Journal of Consulting and Clinical Psychology, 50,
259–272. doi:10.1037/0022-006X.50.2.259
ENRICO JONES 269

23
DAVID A. SHAPIRO:
PSYCHOTHERAPEUTIC
INVESTIGATIONS
MICHAEL BARKHAM, GLENYS PARRY, AND GILLIAN E. HARDY
David Shapiro has made a unique and enduring contribution to psycho-

therapy research over a period of 3 decades and was the first UK member—
and the second non–North American—to be elected international president
of the Society of Psychotherapy Research (SPR), for 1993–1994. The title
of his presidential address—“Finding Out How Psychotherapies Help People
Change” (1995)—encapsulates his classic scientist–practitioner approach
to investigating the psychological therapies, an approach that Shapiro
called psychotherapeutic investigations in reference to Wittgenstein’s Philo-
sophical Investigations, where insights are derived from examining the inex-
tricable links between methods and findings. Shapiro has long been regarded
as preeminent among psychotherapy researchers, a position acknowledged in
2000 when he was awarded both a Lifetime Achievement Award by the UK
chapter of SPR and was the recipient of the M. B. Shapiro Award by the
Division of Clinical Psychology of the British Psychological Society in recog-
nition of his work in the field of psychotherapy research.
271
MAJOR CONTRIBUTIONS
In considering David Shapiro’s major contributions to psychotherapy

research, it is probably easiest to think in terms of research “episodes” across
which runs a golden thread—that of applied science. His skill as a scientist
derived from his ability to combine conceptual clarity with innovative and plu-
ralistic research methodologies, whereas his skill as a practitioner drew heavily
on a combination of his trust in, and willingness to test, the process and theo-
retical basis of any therapy model he was delivering. The vehicle for his deliv-
ery of applied science was the research clinic he established, in which all
therapy was audiotaped (and some videotaped), open to peer-group supervision,
and available as research data. A key axiom of his approach was that he and
members of his team were both clinicians and researchers. Shapiro’s approach
fully embraced the role of the applied scientist. Moreover, although Shapiro
was the research leader, there was always equity in terms of clinical caseload
among members of the group, and he always placed himself under as much
scrutiny as he placed others under.
In addition to combining both roles of scientist and practitioner, Shapiro
and his team trained in contrasting forms of therapy—that is, cognitive behav-
ioral (CB) therapy and psychodynamic interpersonal (PI) therapy—thereby
enabling Shapiro to employ designs in which therapists were crossed with thera-
pies rather than nesting them within treatments. This strategy enabled Shapiro
to address two central research agendas: (a) ensuring delivery of high-quality
research in contrasting psychological therapies and (b) providing a unique data
set to address issues of common factors in the psychological therapies. Shapiro’s
approach to the research process encompassed deeply held personal values about
the importance of providing an even playing field in the evaluation of differ-
ing psychological therapies and mechanisms of change, be they specific or
common. These research themes remain central because many therapies still
lack a high-quality research base and the loss of diversity in psychotherapeutic
approaches is a potential loss to the mental health field and to the aspiration of
giving clients a real choice of evidence-based treatments. In this context, the
significance of Shapiro’s contribution has been as much about the demonstra-
tion of the importance of understanding process in order to develop effective
services as it has been about discovering specific change processes.
EARLY BEGINNINGS
David Shapiro was born in 1945 and grew up on the borders of South
London and Kent, attending Eltham College and winning a Sacher Open
Scholarship in Modern Studies to New College Oxford. There he gained first
272 BARKHAM, PARRY, AND HARDY

class honors in psychology and philosophy. His teachers included Richard
Dawkins, Jeffrey Gray, Rom Harré, Niko Tinbergen, Gilbert Ryle, and Peter
Strawson. He was named proxime accessit to the Henry Wilde Prize in philos-
ophy and almost diverted from his planned career in psychology by the intel-
lectual appeal of graduate work in that field. He then completed an MSc with
distinction in clinical psychology at the Institute of Psychiatry, London. He
stayed at the Institute of Psychiatry on a Medical Research Council (MRC)
studentship to read for his PhD under the supervision of Robert F. Hobson.
Frustration with the limitations of the behavioral paradigm then pre-
dominant at the Institute of Psychiatry led Shapiro to work with Robert
(Bob) Houston. This frustration had already led him to an interest in client-
centered therapy research and to working on understanding and implement-
ing the work of Truax and Carkhuff on therapeutic conditions. Therefore, a
creative research partnership with Bob Hobson was a very attractive propo-
sition for Shapiro’s doctoral work. From that doctoral work, David Shapiro
and Bob Hobson published a number of papers (e.g., Shapiro & Hobson,
1972) that addressed issues of methodology as well as of psychotherapeutic
change processes. Substantive issues addressed included the possible role of
short-term deterioration in the securing of longer term gains from sessions of
psychodynamic therapy.
In 1973, Shapiro moved north to the University of Sheffield to take up a
post as a lecturer in the psychology department, a move influenced by John
Davis, a Sheffield faculty member with an American PhD, who had persuaded
his department to meet students’ dissatisfaction with the dryness of their cur-
riculum by making an appointment in the then-fashionable area of humanistic
psychology, for which Shapiro offered a scientifically acceptable face. In 1977,
Peter Warr—director of the MRC’s Social and Applied Psychology Unit at the
University of Sheffield—took the initiative to add a clinical strand to his
industrial/organizational (or work) psychology unit, and Shapiro was appointed
as team leader, with the brief to set up a program of work focusing on psycho-
logical interventions to support people who were stressed at work. Shapiro
formed a research team whose core members were qualified clinical psy-
chologists serving as both clinicians and researchers. The psychotherapy pro-
gram targeted clients meeting robust clinical criteria who were employed
(typically in white-collar jobs, to minimize variability in occupational status)
and whose mental health problems had an impact on their work.
Throughout this project the group’s research was informed by Shapiro’s
fascination with the process of psychotherapy; his wish to see more thorough
research attention to nonbehavioral therapies, including psychodynamic,
interpersonal, and experiential approaches; and his commitment to pursuing
rigorous psychotherapeutic investigations synthesizing a wide range of research
methods to find out how psychotherapies help people change. The group’s
DAVID A. SHAPIRO 273

strategies and philosophy were intended to exemplify and inform the develop-
ment of the scientist–practitioner model.
ACCOMPLISHMENTS
As a way of framing Shapiro’s research achievements, we have grouped

his work into five episodes: (a) research on client-centered conditions, (b) meta-
analytic research, (c) conceptual and comparative outcome research, (d) process
research, and (e) clinical and service delivery research.
Research on Client-Centered Conditions
Through the early and mid 1970s, Shapiro published a series of articles
focusing on the theme, “What are the ingredients of change?” Shapiro carried
out studies testing key Rogerian concepts, in particular that of empathy. In one
study he evaluated the rating scales devised by Truax and Carkhuff for rating
empathy, genuineness, and nonpossessive warmth and found supporting evi-
dence for the use of the empathy scale but not for the other two conditions
(Shapiro, 1973). He also employed innovative experimental designs using non-
clinical participants with the aim of bringing precision to what had previously
been considered somewhat vague concepts. An exemplar of such work was a
study in which participants attempted to reconstruct the serial order of dia-
logues according to examples defining successive points on the Truax Accurate
Empathy (AE) Scale (Shapiro, 1976). Contrary to expectations, findings
showed a decrease in accuracy with higher AE ratings, suggesting that dialogue
representing higher levels of AE indicated tacit understanding rather than an
explicit structure identifiable to external raters.
Meta-Analytic Work
On his joining the MRC unit in 1977, Shapiro’s focus moved to the ques-
tion of comparative outcomes across therapeutic approaches, working with
Diana Shapiro. Informed by Smith and Glass’s (1977) classic meta-analytic
study on the effects of psychotherapy—a watershed in outcomes research that
had always impressed Shapiro—his work with Diana Shapiro provided him
with a question to be addressed in terms of replicating and refining the Smith
and Glass study. They refined Smith and Glass’s study by implementing a num-
ber of amendments, primarily in response to criticisms made of it by Stanley
Rachman and G. Terence Wilson. The resulting study comprised 143 outcome
studies published between 1975 and 1979 in which two or more psychological
treatments were compared with a control group (Shapiro & Shapiro, 1982).

They drew three primary conclusions from the study. First, the mean of
the 1,828 effect size measures approached one standard deviation, a finding
slightly larger than that reported by Smith and Glass. Second, the relatively
modest differences between treatment methods were largely independent of
other factors. Finally, they concluded that outcome research at that time was
not representative of clinical practice. In a separate review of meta-analysis as
applied to treatment outcomes research, Shapiro concluded that the most
promising application for this methodology lay in “same experiment” data in
which studies compared contrasting conditions within the same experiment.
With typical pithiness, he highlighted the methodological problems of aggre-
gating data collected under differing circumstances: “Between-study confounds
are the enemy of disaggregation” (Shapiro, 1985, p. 33).
Conceptual and Comparative Outcome Studies
The meta-analytic research provided the basis for two parallel streams of
work, each of which captures the clear strengths of Shapiro’s research reper-
toire. One activity focused on a conceptual treatment of issues around evidence
of equivalence of outcomes and its implications for research, in work carried
out collaboratively with Bill Stiles and Robert Elliott. This arose from the
meeting of like-minded scientist–practitioners during the SPR meetings of the
early 1980s and yielded a watershed article titled “Are All Psychotherapies
Equivalent?” in the American Psychologist (Stiles, Shapiro, & Elliott, 1986). The
other activity focused on designing a comparative study of contrasting thera-
pies that investigated the processes as well as the outcomes of therapies. Shapiro
referred to this approach as a “comparative, content-impact-outcome research
strategy.”
David Shapiro was subsequently joined by Jenny Firth (later Firth-
Cozens), Glenys Parry, and Chris Brewin. With Jenny Firth, Shapiro set about
designing a trial to test whether delivering contrasting therapies in differing
sequences might yield enhanced outcomes (Shapiro & Firth, 1987). Two
therapies were selected in terms of their ability to represent broadly differing
approaches: prescriptive (later to be renamed cognitive behavioral [CB]) and
exploratory (later to be renamed psychodynamic interpersonal [PI]) therapy.
A driving concern behind this study, which became known as the (first)
Sheffield Psychotherapy Project, was to generate an even playing field between
contrasting therapies and, in particular, to deliver quality research on non-
CBT approaches. Shapiro, informed by his father’s priority of strategy over pro-
cedure, realized that the evidence base will always be incomplete; for example,
he was always clear that there was no such thing as a “definitive” study—and
its application to many clinical situations would be uncertain. Hence, the most
compelling need for scientist–practitioner skills arises when the evidence is

equivocal or lacking, and he saw a desperate need to evaluate the contribution
of non-CBT models of psychological therapy. In this way, the focus and the
means for testing it relied on building a team of scientist–practitioners.
Although clinical psychology training in the UK at the time was pre-
dominantly CB, the scientist–practitioners were recruited for an evenhanded
approach to PI and CB therapies (as reflected in their training placements).
This evenhandedness and openness to training in both therapy modalities
enabled the studies to be designed with therapists delivering both treatment
modalities. Hence, therapists were crossed with treatments, in contrast to most
research studies, in which separate groups of trained therapists delivered only
one therapy mode.
The Sheffield Psychotherapy Project and the Second Sheffield Psycho-
therapy Project were designed to compare the two treatment modalities—
PI and CB—and to examine explanatory models and processes of change. The
design of the Second Sheffield Psychotherapy Project was replicated in a smaller
effectiveness study carried out in National Health Service (NHS) clinical set-
tings across multiple sites to determine the extent to which the outcome results
could be generalized to NHS outpatients. The final study in the series tested the
two treatment modalities in a very brief format—two-plus-one sessions. While
this quartet of studies held the comparison between PI and CB therapy con-
stant, they variously used differing duration of treatment sessions considered as
an independent variable: two, eight, and 16 sessions. An overarching aim of
these studies was to increase the level of precision of outcome-trials methodol-
ogy as one possible resolution to the equivalence paradox.
The first Sheffield Psychotherapy Project was directly informed by
Shapiro’s meta-analytic work by comparing prescriptive (CB) therapy with
exploratory (PI) therapy within the same experiment and by using a crossover
design to control for patient, therapist, and common factors and giving each
treatment an equal chance to demonstrate efficacy. In addition, it sought to
address issues of treatment sequence effects within eclectic therapy by discov-
ering whether the order of delivering the two different kinds of psychotherapy
made a difference to outcome. The results favored prescriptive therapy,
although this difference was moderate, and confirmed Shapiro’s view that find-
ings of equivalent outcomes may be due to poor control over extraneous ther-
apist, technique, and patient variables that were well controlled in this study.
The outcome was largely unaffected by the order in which the two methods
were offered. However, further analysis showed that the differential effective-
ness of the two treatments was confined to one of the two main therapists—a
clear marker for current interest in therapist effects.
The design of the Second Sheffield Psychotherapy Project employed
Shapiro and his team of clinician–researchers—Michael Barkham, Gillian
Hardy, Shirley Reynolds, and Mike Startup—as therapists, together with a

dedicated interviewer/assessor, in a more sophisticated study testing the
impact of treatment length and severity of depression with a sample of 117
clients (Shapiro et al., 1994).
More specifically, the 1994 study focused on questions of modality—Is CB
more effective and rapid in its effects than PI when delivered by investigators
having no prior allegiance to CB?—and questions of duration—Are 16 sessions
more effective than eight sessions? Crucially, the effect of initial severity
was considered. Overall, the study yielded slight but not robust advantages to
CB therapy, with only the Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961) yielding a medium-size treatment effect
and no evidence that either modality delivered a difference in rate of change.
There was some evidence that 16 sessions were more effective than eight ses-
sions, but data also suggested that therapist–client dyads adjusted the pace of
therapy according to the duration available. There was, however, a significant
interaction between severity and duration, resulting in more severely depressed
clients faring worse when receiving eight rather than 16 sessions. Important,
this result held for both PI and CB treatments. At 1-year follow-up, the signif-
icant difference was between eight sessions of PI, which performed worse than
eight sessions of CB, and 16 sessions of PI or CB. In terms of informing the dose-
effect curve, aggregated results from delivery of two, eight, and 16 sessions sug-
gested a greater degree of linearity than originally proposed by the work of Ken
Howard and colleagues (for a summary, see Shapiro et al., 2003).
Process Studies
Underpinning the design of the Sheffield studies and their comparative

design was a focus on the underlying mechanisms of change. This work was
hugely influenced by Shapiro’s finding a companionship of ideas and ideologies
with colleagues in SPR, notably Marv Goldfried, Bill Stiles, and Robert Elliott,
collaborations with whom were sparked by Shapiro’s attending the 1979 inter-
national meeting of SPR, held that year at St. Catherine’s College in Oxford,
England. All three brought differing theoretical and practice perspectives—
behavioral/eclectic (Goldfried), person-centered (Stiles), and experiential
(Elliott)—but were similarly committed to studying psychological processes
within therapy and open-minded about the commonalities between, as well as
distinctiveness of, differing therapy modalities.
Intensive process work on the first Sheffield Psychotherapy Project in
collaboration with colleagues showed the immediate impacts of the two treat-
ments to be consistent with their theoretical expectations, with exploratory
sessions rated as deeper and more powerful, whereas prescriptive sessions were
rated as smoother and easier. Differential impacts also appeared, whereby sig-
nificant therapy events in prescriptive sessions were more likely to lead to

problem solution and reassuranceand, in exploratory therapy, to awareness
and a sense of personal contact with the therapist. Analyses led by Robert
Elliott using comprehensive process analysis on selected insight events in
exploratory and prescriptive sessions directly informed the development of
the assimilation model by Bill Stiles and colleagues (1990).
Work arising from the Second Sheffield Psychotherapy Project focused
on investigations of common factors as a means of explaining the equivalence
paradox and of developing innovative research methods to study “encompass-
ing” frameworks. For example, an experimentally rigorous but clinically sen-
sitive method was devised for testing the assimilation model and showing how
a problematic experience in PI therapy was successfully incorporated into a
schema (see Shapiro, 1995). Much of the change occurred within a single ses-
sion, a finding that anticipated subsequent work on “sudden gains.” A further
example of encompassing frameworks was the exploration, with Bill Stiles, of
the concept of appropriate responsiveness as an explanation for the limita-
tions of process–outcome “dose–effect” relationships. In addition to theoret-
ical debate, evidence for such an explanation was obtained in observations of
therapist behavior in the two contrasting therapies of the Second Sheffield
Psychotherapy Project.
Shapiro’s early interest in empathy and relationship factors as facilitators
of change was further developed by doctoral students in Sheffield and Leeds
through work on the therapeutic alliance. Innovative qualitative methods were
used to develop alliance rupture markers and the cultural determinants of
the relationship development. Work from the Leeds clinic showed that both
the alliance and therapist competence independently predicted outcome, with
client interpersonal style influencing therapy processes—evidence for the
importance of common mechanisms in psychotherapy change processes.
However, although Shapiro’s research was lauded in many circles, it was
treated with some suspicion in others. This arose, in part, because Shapiro’s
conceptualization of CB therapy was not deemed sufficiently purist, even
though his work on adherence within the studies was as thorough as in any
psychotherapy study. Although Shapiro had a sharpness of mind in relation to
the specifics of research design, implementation, and analysis, he would later
acknowledge that he did not take realistic account of the prevailing academic
context and climate (e.g., the rise of Beckian cognitive therapy in the early
1980s and its effect of marginalizing therapeutic approaches in which behav-
ioral change and skill acquisition were the primary drivers).
Clinical and Service Delivery Research
Over 1992 and 1993, a review by the MRC determined that the Social
and Applied Psychology Unit would be closed, and Shapiro was appointed pro-

fessor of clinical psychology at the University of Leeds. In partnership with the
local mental health services, the University of Leeds established a new research
center—the Psychological Therapies Research Centre (PTRC)—of which he
was director. This new partnership between the University of Leeds (scientific)
and the NHS Mental Health Trust (practice) aimed to improve the quality of
services to people needing psychological therapies by carrying out high-quality
research. A research clinic was established, modeled on the research clinic in
Sheffield but staffed by NHS clinical psychologists working one day per week
at PTRC, and a protocol-based trial developed—the Leeds Depression Project.
PTRC established a CBT clinic for depression that yielded significant work for
the research group on phenomena such as sudden gains and the further devel-
opment of the responsiveness inquiry.
Although the vision of PTRC signaled a bold and courageous venture,
the changing climate led Shapiro to leave the University of Leeds in 1999 but
retain the title of research professor of clinical psychology to 2001 and sub-
sequently honorary professor at the Universities of Leeds and Sheffield from
2001 to 2007. During this time, he established an independent consultancy in
research and training, with projects that included supporting the development
and trialing of a computerized CBT self-help package called Beating the Blues—
subsequently endorsed by the UK’s Department of Health—and training and
supporting a small group of NHS workers (not clinical psychologists) in deliv-
ering PI therapy.
David Shapiro formally retired in April 2007 to pursue what had been
a developing passion for some years, photography, especially of musicians
and artists more generally—exchanging, perhaps, the twin role of scientist–
practitioner for that of technician and artist. The activity provides a rich
environment for David’s abundant skills, ranging from his obsession with
fine detail to his ability to stand back and see the whole picture.
OTHER CONTRIBUTIONS
In the 1970s in the UK, the only journal focusing on clinical psychology
was the British Journal of Social and Clinical Psychology, published by the British
Psychological Society. In 1981, the journal was split into separate journals, and
Shapiro was appointed the first editor of the British Journal of Clinical Psychology,
a position he held for 6 years.
Shapiro’s discovery in 1979 of the SPR meeting at St. Catherine’s
College, Oxford, made him a devoted conference attendee. He was also an
astute organizer and was responsible for bringing the 1983 international meet-
ing to Sheffield at very short notice. From this experience Shapiro saw the
need and potential for establishing a UK chapter, and the decision was taken

to establish a UK chapter of SPR and to hold a UK meeting in the following
year. The selected venue, on the North Yorkshire coast, was one drawn from
Diana Shapiro’s childhood and infused the meeting with personal meaning
for both Shapiros. David Shapiro was the first vice president of the UK chap-
ter of SPR.
A further sphere of influence came with Shapiro’s central involvement
with the Mental Health Foundation Psychotherapy Initiative. Following a
2-day conference in 1993 at Balliol College in Oxford at which key speakers
provided summaries of state-of-the-art issues, Shapiro and Mark Aveline
coedited the book Research Foundations for Psychotherapy Practice (1995). His
involvement in the MHF initiative led him to support subsequent research pro-
grams relating to the development of a core outcome battery, therapist compe-
tence, and adherence rating scales for CBT.
A key contribution made by Shapiro was to the establishment of the
doctoral training program in clinical psychology at the University of Sheffield
that started in 1991. Shapiro worked tirelessly behind the scenes to provide
the argument for the course and its successful establishment. Its existence is
a tribute to his selfless endeavours.
INFLUENCES
Many of the themes in Shapiro’s work have been influenced by his par-
ents, Monte and Jean Shapiro, both of whom were highly committed people
with powerfully independent minds. Monte Shapiro (M. B. Shapiro) came to
the UK from South Africa and became one of a powerful group of clinical
psychologists (including Gwynne Jones, Victor Meyer, Jack Rachman, and
James Inglis) in Hans Eysenck’s department at the Maudsley Hospital in
London in the late 1950s. Monte Shapiro’s central axiom was his espousal of a
stringent methodological approach to building a scientific basis for the assess-
ment and treatment of psychological problems. The whole research culture
intrinsic to the Maudsley and Institute of Psychiatry had a pervasive influence
on David Shapiro’s approach, informing but also showing the potential limita-
tions of single approaches to practice and research. Beyond M. B. Shapiro, the
influence of Bob Hobson is foremost as a researcher and practitioner, with his
commitment to the supervision process and his encouragement to junior staff
pervading Shapiro’s own practice.
Shapiro developed lasting collaborations with Robert Elliott, William
B. Stiles, and Marv Goldfried, and each had a considerable influence
on Shapiro’s work. Their differing theoretical orientations but common inter-
est in researching client change yielded a highly productive program of

American Psychological Association publications using data from the Second
Sheffield Psychotherapy Project.
David Shapiro was very generous in supporting postgraduate students and
junior staff in developing their own interests and careers; all seven research clin-
ical psychologists who worked in his team at the Social and Applied Psychology
Unit subsequently becoming professors of clinical psychology. David and Diana
also developed lifelong friendships with many UK clinical psychologists,
especially those involved in training, including Chris Barker and Nancy
Pistrang, John and Marcia Davis, Chris Leach, and David Kennard.
CONCLUSION
Through his investment in researching the process of outcomes and his

commitment to methodological rigor, Shapiro has made a substantial contri-
bution to psychological therapies research. Perhaps more than any specific
research finding per se, the hallmarks of his work have been the combination
of his philosophical approach and evenhandedness; the former based on his
belief that insights are derived from examining the inextricable links between
methods and findings, and the latter based on a social and scientific principle
of providing a level playing field as the only basis for carrying out psychother-
apeutic investigations.
REFERENCES
Aveline, M., and Shapiro, D. A. (1995). Research foundations for psychotherapy practice.
Chichester, England: Wiley in associations with the Mental Health Foundation.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inven-
tory for measuring depression. Archives of General Psychiatry, 4, 561–571.
Shapiro, D. A. (1973). Naïve British judgements of therapeutic conditions. British
Journal of Social and Clinical Psychology, 12, 289–294.
Shapiro, D. A. (1976). Conversational structure and accurate empathy: An exploratory
study. British Journal of Social and Clinical Psychology, 15, 213–215.
Shapiro, D. A. (1985). Recent applications of meta-analysis in clinical research.
Clinical Psychology Review, 5, 13–34. doi:10.1016/0272-7358(85)90027-3
Shapiro, D. A. (1995). Finding out how psychotherapies help people change. Psycho-
therapy Research, 5, 1–21.
Shapiro, D. A., & Firth, J. (1987). Prescriptive vs. exploratory psychotherapy:
Outcomes of the Sheffield Psychotherapy Project. British Journal of Psychiatry, 151,
790–799. doi:10.1192/bjp.151.6.790

Shapiro, D. A., & Hobson, R. F. (1972). Change in psychotherapy: A single case
study. Psychological Medicine, 2, 312–317. doi:10.1017/S0033291700042628
Shapiro, D. A., & Shapiro, D. (1982). Meta-analysis of comparative therapy out-
come studies: A replication and refinement. Psychological Bulletin, 92, 581–604.
doi:10.1037/0033-2909.92.3.581
Shapiro, D. A., Barkham, M., Rees, A., Hardy, G. E., Reynolds, S., & Startup, M.
(1994). Effects of treatment duration and severity of depression on the effective-
ness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy.
006X.62.3.522
Shapiro, D. A., Barkham, M., Stiles, W. B., Hardy, G. E., Rees, A., Reynolds, S., &
Startup, M. (2003). Time is of the essence: A selective review of the fall and rise
of brief therapy research. Psychology and Psychotherapy: Theory, Research and
Practice, 76, 211–235.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies.
American Psychologist, 32, 752–780.
Stiles, W. B., Elliott, R., Llewelyn, S. P., Firth-Cozens, J. A., Margison, F. R., Shapiro,
D. A., & Hardy, G. (1990). Assimilation of problematic experiences by clients
in psychotherapy. Psychotherapy, 27, 411–420.
Stiles, W. B., Shapiro, D. A., & Elliott, R. (1986). Are all psychotherapies equivalent?
American Psychologist, 41, 165–180.

24
ROBERT ELLIOTT: COMMITMENT
TO EXPERIENCE
RHEA PARTYKA
One of Robert Elliott’s most influential contributions to the field of

psychotherapy research has been his development of highly innovative and
rigorous quantitative and qualitative research methods for the empirical eval-
uation of clients’ accounts of change in psychotherapy. Early in his career he
began to systematically explore clients’ experiences of significant events in
therapy. This research initiative paved the way for his further studies on the
perceived helpfulness of therapist response modes and eventually led to the
development of a taxonomy of helpful and hindering therapy events. To
undertake a more thorough investigation of these events, he developed the
comprehensive process analysis (CPA) method to more fully address the con-
text in which significant events occur in psychotherapy sessions. This method
was later applied in examining insight events in both psychodynamic and
cognitive–behavioral therapy modalities. Brief structured recall (BSR) was then
developed as a more focused method for measuring and collecting information
on significant therapy events. In an effort to more fully understand causality
in the change process, Elliott developed the hermeneutic single case efficacy
design (HSCED). An adjudicational model of this method was later used
for assessing psychotherapy outcome. Most recently, Elliott and colleagues
283
introduced a new psychometric method—Rasch analysis—for the analysis of
common therapy outcome measures.
In addition to his contributions in research methods, Elliott has also
played a vital role in the development of process–experiential (PE) therapy
(also known as emotion-focused therapy, or EFT) and its application to various
types of clients and presenting issues. He has worked with colleagues to develop
a model of how clients progress through experiential tasks, which has led to the
publication of influential PE treatment and training manuals. In fact, he has
become an internationally recognized expert in PE training and supervision.
Furthermore, Elliott’s research on PE therapy and depression has made a sig-
nificant contribution to the recent recognition of PE therapy (EFT) as an
empirically supported treatment of depression by APA Division 12 (Society of
Clinical Psychology).
EARLY BEGINNINGS
The oldest of six children, Elliott was raised in California and describes
his parents as intellectuals. Strongly influenced by his father, he attributes the
use of humor in his work, as well as his desire to understand and help others, to
experiences with his dad. Moreover, Elliott also shared a passionate interest in
science fiction with his father and, as a young man, thought he would become
a science fiction writer when he grew up. A turning point in his career aspira-
tions occurred after he read Karen Horney’s Our Inner Conflicts (1945) as part
of a high school creative writing course. His mother and grandmother shared
an interest in Jungian psychology, and his grandmother, a writer, was also
quite interested in the field of parapsychology, hoping one day her grandson
would become a parapsychologist. Although parapsychological concepts
seemed too ephemeral and abstract to Elliott, he realized observable psycho-
logical processes, such as empathy and the therapeutic interaction, discovered
in Horney’s writing, could be equally powerful and intellectually challenging.
He came to view empathy and therapy as “magical” in their power to transform
human experiences, about the time he realized that he wanted to become a
therapist—which he naively imagined as a kind of magician/healer—an insight
he described as similar to a religious conversion.
Elliott’s undergraduate training at the University of California–Santa
Cruz (UCSC) was primarily humanistic in nature, especially as UCSC was
home to several influential humanistic psychologists, including Ted Sarbin,
Brewster Smith, Frank Barron, and Bert Kaplan. During college and graduate
school, Elliott’s goal was to become a therapist; however, his professors recog-
nized his talent as a “natural academic” and suggested that he also pursue
research. He began his clinical training in graduate school at the University of
284 RHEA PARTYKA

California–Los Angeles (UCLA), however, with a perspective more consis-
tent with that of a social behaviorist. At this time, he was also influenced by
his advisor, Jerry Goodman, who provided Elliott with foundational training
in client-centered therapy. Elliott’s clinical externships included Veterans
Administration hospitals, where he worked with acutely psychotic patients and
a child and family guidance clinic. He completed his internship at UCLA’s stu-
dent mental health clinic. While attending his first conference for the Society
for Psychotherapy Research (SPR) in 1976, Elliott met Leslie Greenberg and
Laura Rice, and the following year he heard them present research findings on
gestalt two-chair work for conflict splits and systematic unfolding for problem-
atic reactions that inspired him to incorporate those methods into his practice.
He acknowledges Rice and Greenberg’s research as the strongest influence on
his practice as a therapist. At the same time, he has consistently seen SPR as
his key scientific organization and reference group; he has not missed an inter-
national SPR conference since his first in 1976!
By the time he completed his PhD and accepted an academic clinical
faculty position at the University of Toledo, he identified himself as an
eclectic–integrative therapist, utilizing a wide variety of therapy techniques
conceptualized within a broadly psychodynamic framework. During that
time, Elliott took pride in his ability to make sense out of complex phenomena,
and he found enjoyment in developing and offering interpretations to clients;
however, over time he became increasingly aware of his uncertainty regarding
whether his interpretations actually helped his clients. He initiated the psycho-
therapy research program at the University of Toledo in 1978 and subsequently
immersed himself in the study of client in-therapy experiences, close analysis
of therapy process, effective ingredients in therapy, results of relevance to clin-
ical practice and training, and development and testing of new measures and
research approaches for capturing psychotherapeutic change processes.
ACCOMPLISHMENTS
Innovative Research Methodologies
While in graduate school at UCLA, Elliott and fellow students Chris

Barker and Nancy Pistrang developed an application of Kagan’s interpersonal
process recall procedure for the systematic investigation of client experiences
of particular moments in therapy (Elliott, 1986). During the course of this
research, Elliott came to the dual realization that while therapists are often
unaware of how their clients perceive the therapy process, clients are active,
aware processors of their therapy experiences. This insight resulted in Elliott’s
becoming a more cautious, inquiring therapist. In addition, these data led him
ROBERT ELLIOTT 285

to develop an interest in significant change events in therapy. His early
studies at the University of Toledo (Elliott, Barker, Caskey, & Pistrang, 1982)
focused on the perceived helpfulness of therapist response modes. Through
these studies, the existence of very helpful or “significant” therapist interven-
tions was discovered. A subsequent study involved volunteer clients who were
asked to identify and describe the impact of the most and least helpful thera-
pist responses in brief counseling sessions. A cluster analysis of these client
descriptions resulted in his highly influential taxonomy of helpful and hinder-
ing therapy events (Elliott, 1985).
Through the process of analyzing helpful and hindering therapy events,
Elliott became increasingly aware of a need for developing qualitative proce-
dures to more fully capture the nature of these events. Furthermore, he recog-
nized a need to consider not only the events themselves but also the full context
in which these events occurred. Accordingly, he developed CPA (Elliott,
1984), an interpretive, inductive qualitative research method that is based on
the assumption that identifying and analyzing particular instances of a phenom-
enon is necessary in order to understand that phenomenon more generally.
CPA involves the examination of three domains: context, key responses, and
effects. Context refers to the factors and events that lead up to or are exempli-
fied by the event, such as background, presession context, session context, and
episode context. Key responses consist of four aspects of the most helpful thera-
pist or client responses: action, content, style, and quality or skilfulness. Effects
involve the sequentially unfolding consequences of an event, including its
immediate effects within the episode, its delayed effects within the same or later
sessions, and the clinical significance of the event.
For example, Elliott and colleagues’ CPA of insight events in cognitive
behavioral (CB) and psychodynamic interpersonal (PI) psychotherapies
(Elliott et al., 1994) first entailed each analyst’s independently explicating the
implicit meanings in key therapist speaking turns and the client’s postsession
description of the event. Next, the analysts met to develop a consensus expli-
cation of these meanings. Third, each analyst independently used the CPA
framework to analyze the individual events, and then the entire team of judges
carried out a cross-analysis of six events with a goal of identifying common and
discriminating factors. Common factors included the presence of what Rice and
Sapiera (1984) called a problematic reaction point and a meaning bridge. Elliott
and colleagues’ analyses led to the development of a sequential model of insight
reflecting the progression through contextual priming, presentation of novel infor-
mation, initial distantiated processing, insight, and elaboration. The CPA analyses
also established that a client’s experience of insight may vary in different ther-
apeutic modalities. Specifically, CB insight events were found to be primarily
reattributional in nature, whereas PI insight events involved connection to a
conflict theme and the expression of painful affect. These research findings
286 RHEA PARTYKA

have important implications for psychotherapy researchers interested in iden-
tifying core principles of change in psychotherapy.
Elliott and his colleagues eventually came to view the data they had been
using to conduct CPA—therapy transcripts and postsession descriptions—as
not detailed enough to support the method. This led to the development of
BSR (Elliott, 1993; Elliott & Shapiro 1988), a form of tape-assisted recall used
for the identification and description of significant client events in psycho-
therapy, utilizing both qualitative and quantitative collection procedures. The
most basic BSR format entails the completion of a semistructured interview
schedule that addresses the three major domains of CPA (context of event,
major process involved, and effect of the event on the client). A more detailed
format (Brief Structured Recall Version 3.5) utilizes rating scales to obtain
numerical data on psychometrically evaluated measures of event helpfulness,
therapist and client intentions, client feelings, and client reactions in addition
to allowing for open-ended descriptions of experiences (Elliott, 1989).
Elliott’s early CPA studies were based on several assumptions: Open-
ended questions are largely used to gather descriptive data, words (as opposed
to numbers) are used to describe phenomena, a small number of cases are inten-
sively studied, and context is necessary to understand the experience. The CPA
method formed the basis for a research method that later became known as con-
sensual qualitative research (CQR), which also uses consensus and auditing
procedures to reduce various forms of researcher error and narrowness. The full
CQR method was initially applied in McGlenn’s (1990) dissertation on clients’
experiences of important weeping moments. Elliott passed this approach on to
Clara Hill, who developed CQR further and applied it in numerous studies on
a range of aspects of counseling (see Chapter 13, this volume).
Elliott also developed a greater interest in understanding the change
process, and he was motivated to develop a method driven largely by data. The
HSCED (Elliott, 2002) is an interpretive approach to evaluating treatment
causality in single therapy cases. This particular approach uses a blend of quan-
titative and qualitative methods to create a network of evidence that identifies
direct examples of causal links between therapy process and outcome and then
evaluates plausible nontherapy explanations for apparent client change. The
HSCED seeks to answer three questions: (a) Has the client actually changed?
(b) Is psychotherapy generally responsible for the change? and (c) What spe-
cific factors (both within therapy and outside of therapy) are responsible for the
change? The first prerequisite for the HSCED is a rich case record detailing
aspects of the client’s therapy. Several sources of data are typically used. First,
quantitative outcome measures are utilized to determine the extent to which the
client changed. Second, a weekly outcome measure is used to identify the client’s
main therapy-related problems or goals and to measure their weekly level of
distress related to these specific issues. Third, a qualitative outcome assessment is
ROBERT ELLIOTT 287

conducted, during which clients are asked to provide descriptions of any
changes experienced over the course of therapy as well as their attributions for
these changes. Fourth, qualitative information about significant events is collected.
Lastly, therapist accounts of the therapy process are gathered.
Influenced by Bohart’s (2000) adjudicational model for assessing
psychotherapy outcome, Elliott and his team then developed an adjudication
model for the HSCED and applied it in a case study involving a male client
with panic disorder (Elliott, Partyka, Wagner, Alperin, & Dobrenski, 2003).
The first stage of this model entails the critical review of evidence that supports
the conclusion that psychotherapy was a major causative source of assessed
client change. Examples of direct evidence include restrospective attribution,
outcome-to-process mapping, event-shift sequences, and change in stable prob-
lems. A valid evaluation of potential client change must also include a good-
faith effort to identify evidence that refutes the causal role of therapy. Examples
of such negative evidence include trivial or negative change, statistical artifacts,
relational artifacts, expectancy artifacts, self-help or other self-correction
processes, extratherapy life events, psychobiological processes, and the reactive
effects of taking part in research.
As a final example of his scientific creativity and commitment to
both qualitative and quantitative methods, Elliott and colleagues from the
University of Toledo (Elliott, Fox, Beltyukova, Stone, Gunderson & Zhang,
2006) recently published an article illustrating the use of a powerful new
psychometric research tool, Rasch analysis. The Rasch model is a type of
item response model specifying that useful measurement consists of a single-
dimensional concept arranged in a consistent pattern along an equal-interval
continuum. Instruments calibrated using Rasch modeling enable one to deter-
mine the extent to which items have consistently measured a single variable.
Further, Rasch statistics assist in the evaluation of the constructed metric. For
instance, Rasch analysis can identify gaps in the construct continuum by iden-
tifying items and persons that are not well targeted. In Elliott and colleagues’
(2006) study, several forms of Rasch analysis were applied to the Symptom
Checklist-90-R (Derogatis, 1983) to obtain a greater understanding of the
strengths and limitations of this common therapy outcome measure and to illus-
trate the utility of Rasch analysis for psychotherapy outcome measurement. In
fact, Elliott has described Rasch analysis as “the next wave of psychometric
research.”
Development of Process–Experiential Therapy
On sabbatical in England in 1985, Elliott was influenced by the work

of David Shapiro and the first Sheffield Psychotherapy Project, a complex
process–outcome study comparing CB and interpersonal dynamic treat-
288 RHEA PARTYKA

ments of depression (Shapiro & Firth, 1987). While presenting at a confer-
ence in England, Elliott was confronted by a member of the audience, a
psychoanalyst, who drew attention to the inconsistency between his willing-
ness to offer an interpretation of his client’s dreams and his unwillingness to
make such high-level inferences regarding clients in his own research. This
insight served as a key turning point in Elliott’s development as a psycho-
therapist and reinforced his commitment to the value of understanding his
clients’ internal experiences. It was in light of this experience that Elliott also
decided to focus his work as a therapist and researcher within a particular
therapeutic approach, client-centered/experiential psychotherapy.
Upon his return to the United States, Elliott and his students decided
to initiate a study parallel with the Sheffield project. Motivated by a need to
broaden the range of treatments available for working with depression and
recognizing the relative scarcity of recent work on humanistic or experiential
therapies, they chose to use an integrative experiential therapy based on a task
analytic approach (Rice & Greenberg, 1984). At that time, the task interven-
tions did not yet amount to an internally coherent treatment, and a comprehen-
sive theory of treatment and the change process had yet to be fully developed.
Greenberg and Rice invited Elliott to collaborate on the further articula-
tion of the therapeutic model, and together with Clark they drafted a treatment
manual for depression (Elliott, Greenberg, Rice, & Clark, 1987). The primary
research questions focused on change processes, particularly the identification
of types of significant events and the factors that contribute to them, as well as
assessment of the outcome and change processes in the treatment.
The emerging approach was called process–experiential therapy to distin-
guish it from other experiential treatments. This form of therapy set out to inte-
grate key elements of client-centered and gestalt therapies. Elliott utilized his
background of previous research on therapist response modes (Elliott, 1979,
1985; Elliott et al., 1987) to develop a description of the therapist’s experien-
tial response modes used in PE therapy. Elliott and his students conducted a
process–outcome study of PE therapy with major depressive disorder. Through
their work as therapists in the study, they were able to work toward the devel-
opment of a general treatment model as well as its specific application to depres-
sion (Elliott et al., 1990; Greenberg, Elliott, & Foerster, 1990). This research
served as a foundation for Elliott to collaborate with Les Greenberg to develop
a description of practical treatment issues and propose a general model of how
clients progress through the different experiential tasks. This work resulted in
an extensive treatment manual (Greenberg, Rice, & Elliott, 1993), largely
informed by research.
In 1992, Elliott undertook a sabbatical in Toronto and began work
on a major review chapter addressing the efficacy of experiential humanis-
tic psychotherapies (Greenberg, Elliott, & Lietaer, 1994). His decision to
ROBERT ELLIOTT 289

undertake a meta-analysis of all available outcome research pertaining to
experiential–humanistic therapies resulted in the following conclusions:
Clients who participate in experiential therapies show, on average, large
amounts of change over time; posttherapy gains in experiential therapies are
stable through both early and late follow-ups; clients in experiential thera-
pies show substantially more change than comparable untreated clients in
randomized clinical trials; and clients in experiential therapies show gains
that are comparable to those in clients seen in nonexperiential therapies,
including cognitive behavioral treatments. Based on these results, later
updated and strengthened, Elliott et al. (2003) asserted that “the evidence
is now strong enough for us to recommend that experiential-humanistic
therapies should be considered empirically supported treatments. In fact, stu-
dents’ education as psychologists is incomplete without a greater emphasis
on such training.” It should be noted that, at the time of this writing, the
process–experiential approach, now also known as emotion-focused therapy
(EFT), will be recognized as an empirically supported treatment of depres-
sion by APA Division 12.
From 1993 to 2005, Elliott continued to develop and expand PE therapy.
He also focused much of his attention on training students and wrote or collab-
orated on several books, including Learning Emotion-Focused Therapy (Elliott,
Watson, Goldman, & Greenberg, 2004). After retiring from the University of
Toledo in July 2006, he moved to Glasgow, Scotland, to become professor of
counseling in the Counseling Unit at the University of Strathclyde, one of the
largest person-centered therapy training centers in Europe. He describes his cur-
rent interests as a culmination of his earlier research. In addition to conducting
practice-based and interpretive case study research, he is also developing an
emotion-focused therapy approach for individuals with social anxiety. In addi-
tion, he has also started on students’ outcomes and change processes in therapy
training. He is currently involved in encouraging similar efforts in Europe and
North America.
PROFESSIONAL CONTRIBUTIONS AND CONCLUSION
Robert Elliott has held many leadership positions within the field of
psychotherapy research. He served as president of the North American Chapter
of the Society for Psychotherapy Research (SPR) in 1991, and he served as
president of the international SPR in 2000–2001. He has served as North
American editor of Psychotherapy Research (1994–1998) and as coeditor of
Person-Centered and Experiential Psychotherapies (2002–2007). When describ-
ing his leadership positions and his role as a journal editor, Elliott stated, “It’s
a way for me to give back what has been given to me.” Most recently, Elliott
290 RHEA PARTYKA

was named the recipient of the 2008 Carl Rogers Award of APA’s Division of
Humanistic Psychology.
Finally, it is important to note that Robert Elliott has significantly influ-
enced the clinical development of numerous students and is an inspiring and
trusted colleague to many seasoned researchers and clinicians. Simply stated,
he is a person who cares deeply about his students and colleagues and embod-
ies the values of genuineness, authenticity, and warmth that define the practice
of person-centered and experiential therapies.
REFERENCES
Bohart, A. C. (2000, June). A qualitative “adjudicational” model for assessing psychother-

apy outcome. Paper presented at meeting of Society for Psychotherapy Research,
Chicago, IL.
Derogatis, L. R. (1983). SCL-90-R administration, scoring and procedures manual-II.
Towson, MD: Clinical Psychometric Research.
Elliott, R. (1979). How clients perceive helper behaviors. Journal of Counseling
Psychology, 26, 285–294. doi:10.1037/0022-0167.26.4.285
Elliott, R. (1984). A discovery-oriented approach to significant events in psycho-
therapy: Interpersonal process recall and comprehensive process analysis. In
L. N. Rice & L. S. Greenberg (Eds.), Patterns of change (pp. 249–286). New York,
NY: Guilford Press.
Elliott, R. (1985). Helpful and nonhelpful events in brief counseling interviews: An
empirical taxonomy. Journal of Counseling Psychology, 32, 307–322. doi:10.1037/
0022-0167.32.3.307
Elliott, R. (1986). Interpersonal Process Recall (IPR) as a psychotherapy process
research method. In L. Greenberg & W. Pinsof (Eds.), The psychotherapeutic process
(pp. 503–527). New York, NY: Guilford Press.
Elliott, R. (1989). Comprehensive process analysis: Understanding the change process
in significant therapy events. In M. Packer & R. B. Addison (Eds.), Entering the
circle: Hermeneutic investigation in psychology (pp. 165–184). Albany, NY: State
University of New York Press.
Elliott, R. (1993). Comprehensive process analysis: Mapping the change process in
psychotherapy. Unpublished research manual, University of Strathclyde, Glasgow,
Scotland.
Elliott, R. (2002). Hermeneutic single case efficacy design. Psychotherapy Research, 12,
1–21. doi:10.1080/713869614 http://pe-eft.blogspot.com/2007/02/my-journey-
as-therapist-as-symphony-in.html
Elliott, R., Barker, C.B., Caskey, N., & Pistrang, N. (1982). Differential helpful-
ness of counsel or verbal response modes. Journal of Counseling Psychology, 29,
379–387.
ROBERT ELLIOTT 291

Elliott, R., Clark, C., Wexler, M., Kemeny, V., Brinkerhoff, J., & Mack, C. (1990).
The impact of experiential therapy of depression: Initial results. In G. Lietaer,
J. Rombauts, & R. Van Balen (Eds.), Client-centered and experiential psychotherapy
towards the nineties (pp. 549–577). Leuven, Belgium: Leuven University Press.
Elliott, R., Fox, C., Beltyukova, S., Stone, G., Gunderson, J., & Zhang, X. (2006).
Deconstructing therapy outcome measurement with Rasch analysis of a measure
of general clinical distress: The Symptom Checklist-90-Revised. Psychological
Assessment, 18, 359–372.
Elliott, R., Greenberg, L. S., Rice, L.N., & Clark, C. (1987). Draft manual for experi-
ential therapy of depression. Unpublished manuscript, Department of Psychology,
University of Toledo, Toledo, OH.
Elliott, R., Hill, C. E., Stiles, W. B., Friedlander, M. L., Mahrer, A., & Margison, F.
(1987). Primary therapist response modes: A comparison of six rating systems.
Journal of Consulting and Clinical Psychology, 55, 218–223.
Elliott, R., Partyka, R., Wagner, J., Alperin, R., & Dobrenski, R. (2003). An adjudi-
cated hermeneutic single case efficacy design study of experiential therapy for panic
disorder: Case record and arguments. Unpublished paper, University of Toledo,
Toledo, OH.
Elliott, R., & Shapiro, D.A. (1988). Brief structured recall: A more efficient method for
identifying and describing significant therapy events. British Journal of Medical
Psychology, 61, 141–153.
Elliott, R. Shapiro, D. A., Firth-Cozens, J., Stiles, W. B., Hardy, G., Llewelyn, S. P., &
Margison, F. (1994). Comprehensive process analysis of insight events in
cognitive-behavioral and psychodynamic-interpersonal therapies. Journal of
Counseling Psychology, 41, 449–463.
Elliott, R., Watson, J., Goldman, R., & Greenberg, L. S. (2004). Learning emotion-
focused therapy: The process experiential approach to change. Washington, DC:
Greenberg, L. S., Elliott, R., & Foerster, F. (1990). Experiential processes in the
psychotherapeutic treatment of depression. In N. Endler & D.C. McCann
(Eds.), Contemporary perspectives on emotion (pp. 157–185). Toronto, Canada:
Wall & Emerson.
Greenberg, L. S., Elliott, R., & Lietaer, G. (1994). Research on humanistic and expe-
riential psychotherapies. In A. E. Bergin and S. L. Garfield (Eds). Handbook of
psychotherapy and behavior change, 4th ed. (pp. 509–539). New York, NY: Wiley.
Greenberg, L. S., Rice, L. N. & Elliott, R. (1993). Facilitating emotional change. New
York, NY: Guilford Press.
Horney, K. (1945). Our inner conflicts: A constructive theory of neurosis. New York, NY:
Norton.
McGlenn, M. L. (1990). A qualitative study of significant weeping events. PhD disserta-
tion, Department of Psychology, University of Toledo, Toledo, OH. . (Available
from ProQuest, publication number AAT 9104085, Document ID 744819641.)
292 RHEA PARTYKA

Rice, L. N., & Greenberg, L. S. (Eds.) (1984). Patterns of change. New York, NY:
Guilford Press.
Rice, L. N., & Sapiera, E. P. (1984). Task analysis and the resolution of problematic
reactions. In L. N. Rice & L. S. Greenberg (Eds.), Patterns of change (pp. 29–66).
Shapiro, D. A., & Firth, J. (1987). Prescriptive vs. exploratory psychotherapy:
Outcomes of the Sheffield psychotherapy project. British Journal of Psychiatry, 151,
790–799.
ROBERT ELLIOTT 293

25
WILLIAM B. STILES: EMPATHIC
REFLECTIONS, VOICES,
AND THEORY BUILDING
MEREDITH GLICK BRINEGAR AND KATERINE OSATUKE
William B. Stiles has touched the field of psychotherapy through his

research, teaching, and mentoring. Bill, as most people know him, has a quiet,
unassuming presence that belies the impact his work has had on understand-
ing therapy process, outcome, and related theoretical issues. This chapter
summarizes his contributions, highlighting several major pieces: his work on
verbal response modes, the assimilation model, process–outcome research,
and the use of qualitative methods. A uniting element of his work has been
generating theoretical explanations for existing psychotherapy findings, or
what Bill calls theory building.
BEGINNINGS
William B. Stiles was born in Seattle, the first of four children, and grew
up in the Washington, DC, area. He did his undergraduate studies at Oberlin,
the historically liberal college in Ohio that his wife, parents, siblings, and
many other relatives have attended. He had planned on majoring in econom-
ics but decided to pursue psychology because, he admits, his grades were good
in that field and mediocre in everything else. In hindsight, Stiles speculated
295
that his higher grades reflected interest in the subject, but at the time he inter-
preted it as differential aptitude. Stiles first became aware of his interest in
psychology and personality when discussing his student paper on psychopaths
with his clinical psychology instructor, John Thompson. A decision to pur-
sue graduate studies seemed like a natural fit for him; he came from an academ-
ically minded family. His father was a specialized librarian, his mother a
primary school teacher, his brother a biology professor, and his maternal grand-
father (a junior high school principal) had always wanted to be a professor.
Stiles was accepted into the clinical psychology doctoral program at the
University of California–Los Angeles (UCLA), where his interest in theory
building gradually came to focus on psychotherapy research. He saw psychol-
ogy as a science “not all thought through.” It offered the challenge of explain-
ing complex phenomena in a rich way, without oversimplifying and without
losing methodological rigor. Stiles’s UCLA training was half clinical and half
neuroscience. His dissertation focused on a theory of human experience (e.g.,
grief, anger, sexual excitement) and was neurologically based. This early study
foreshadowed his approach to explaining something as broad as human expe-
rience, by articulating theoretical concepts and grounding them in observa-
tions. Stiles’s specific interest in psychotherapy research emerged out of
doing, supervising, and teaching therapy. It reflected his attempt to under-
stand more thoroughly what happens in therapy. He was strongly influenced
by a clinical supervisor at UCLA, Jerry Goodman, who studied response
modes: a classification of possible responses in an interview setting. Studying
therapy offered Stiles a chance to explain real-world psychological processes,
with both realism and precision.
By the time of his graduation, Bill Stiles had decided to look for an aca-
demic position in clinical psychology, finding the openness of the field
appealing. After completing his internship at the Neuropsychiatric Institute
at UCLA Center for Health Sciences, he became an instructor and then an
assistant professor at the University of North Carolina, Chapel Hill. After
reading Carl Rogers’s work, he adopted a student-centered, nondirective form
of teaching. He developed a career-long reputation for teaching classes in a
radically nondirective way. His students had a hand in developing the syl-
labus, choosing their own readings, structuring group discussions, and evalu-
ating themselves. Although this nontraditional classroom environment often
elicited strong reactions (both positive and negative), Stiles’s students had
opportunities to learn and grow in ways previously unimagined. Stiles is well
known for his use of empathic reflections: Usually accurate, they can be both
irritating and therapeutic. A typical sequence reported by students who have
been exposed to his manner of teaching is, first, feeling left to their own
devices, then resenting it, deciding to fend for themselves, and then eventu-
ally discovering a new level of professional independence or developing a new
296 BRINEGAR AND OSATUKE

level of skill. When Stiles’s students—graduate or undergraduate—reflect on
their experiences with him, they often observe striking similarities. Some
express self-directed humor or new awareness into how this seems to have
worked, others note some remaining guilt over their initial resentment, but
almost all report gratitude for having been helped to discover a new level of
professional autonomy they had not conceived of before.
Stiles’s relatively pure Rogerian approach (an interest in the other per-
son’s experience and how it evolves, rather than in techniques to make peo-
ple think or act in certain desirable ways) is present in all of his professional
roles. For example, whether he is a teacher, mentor, supervisor, coinvestiga-
tor, or senior colleague, he offers an attentive and respectful way of listening,
openness to different perspectives, and willingness to clarify those parts that
seem hard to understand or explain. His consistency in interacting in this
nondirective way, across domains, illustrates how well he has integrated this
theory into his way of being.
Stiles returned to Ohio in 1979 to assume the position of associate pro-
fessor at Miami University. While there, he served for a period as director of
the departmental training clinic, overseeing clinically relevant research con-
ducted by trainees. He also developed a practice of writing in the morning at
home and then walking to the psychology department each afternoon to
teach and meet with students. Although some days are more productive than
others, Stiles has commented that this practice has had an enormous impact
on advancing his thinking and productivity. Stiles’s disciplined approach to
writing seems to have paid off; he is the author of countless journal articles,
book chapters, and conference presentations.
Stiles often organizes weekly research team meetings, currently known
as the Assimilation Research Group (ARG). True to his client-centered
roots, he allows the team to set the agenda, whereby, typically, Stiles and his
graduate students take turns presenting research ideas, study results, or paper
drafts for group feedback. He models how to be open to criticism and always
honors student input on his own work, despite differences in experience
level. For example, if a student felt confused by a certain idea or sentence he
had written, he would note that this reaction likely represented a portion of
how reviewers or other readers would respond, and he then would make
changes accordingly. Stiles has a quiet, steady, and thoughtful presence. He
responds to e-mail messages almost instantly—even from exotic locations—
providing dependable communication to students and colleagues alike.
He is also fairly unassuming—from his casual dress and sandwiches made
on homemade bread, to his quiet manner of speaking and way of putting
complex ideas in simple, jargon-free language. Interacting with him invites
others to drop pretenses, making it easier to clarify and focus on what really
matters to them.
WILLIAM B. STILES 297

When mentoring individual projects, Stiles has long remained committed
to supporting students’ own interests. Just like students in classes he teaches, his
advisees often experience frustration with his lack of directiveness and tendency
toward (usually accurate) empathic reflections. Over time, they typically appre-
ciate the chance to find a project and style of working that truly fits them. Stiles’s
students often take longer finding their way but are rewarded with an increase
in self-trust, autonomy, and an authentic research project that they truly own.
To be sure, Stiles is not entirely nondirective in his mentoring. Any of his stu-
dents who have received his feedback on writing will confirm that his edits,
although usually helpful and respectful, are profuse, direct, and in color
(these days, Bill uses the Track Changes feature in Microsoft Word: additions/
comments in blue, deletions in red). Always respectful of the other person’s
experience, Stiles typically qualifies his numerous edits with “Use as you see fit.”
A summary of Stiles’s biographical details would not be complete with-
out mention of his wife, Sue. They were married December 30, 1967, in New
York City. Stiles recalls that afterward they took a train from Montreal to
Vancouver and then drove down the coast to Los Angeles, where he was in
graduate school. It seems appropriate that their married life started out with
adventuresome travels, given that they have spent a good part of their lives
since then in traveling the world together, for Stiles’s research, for Sue’s writ-
ing, and for pleasure. Following in the footsteps of her father and grandfather,
Sue has training and experience as a journalist. Her focus has been on travel
writing. Stiles describes her as his first and best editor and says that she taught
him how to write clearly and succinctly. She has emphatically declared, how-
ever, that she is not a psychotherapy researcher. With Sue’s talent for writing
and her kind, unassuming presence, it is easy to see how they have developed
a wonderful partnership.
ACCOMPLISHMENTS
Theory Building
Stiles’s favorite aspect of studying psychotherapy involves formulating

and honing a theory of human experience. In his view, scientific theories are
built by gradually integrating various observations, not through a single act
of discovering the whole truth. Knowledge is constructed on the basis of the
assumption that the world is capable of being understood. The construction
of truth is an iterative process; Stiles has explained that in his own theoreti-
cal pursuit, he had to repeatedly ask what was even meant by “truth” (Stiles,
1981, 2006). To this day, Stiles continues to refine his theories about psycho-
therapy and theories about theory.

One of Stiles’s first theoretical forays was an article on the development
of intense relationships.Humorously entitled “Psychotherapy Recapitulates
Ontogeny: The Epigenesis of Intensive Interpersonal Relationships” (Stiles,
1979a), it drew a parallel between personal development in the relational
context and biological growth, in which organisms repeat chronological
stages of their species’ evolution (i.e., ontogeny recapitulates phylogeny). On
the basis of his experience facilitating nondirective process groups with under-
graduates, Stiles proposed that intense interpersonal relationships contri-
bute to personal growth by allowing people to recapitulate, and possibly
heal, psychosocial conflicts in their prior development. To the extent that
psychosocial development is similar across people (Erikson’s “eight ages of
man”), the evolution of a person’s interpersonal stances, needs, and attitudes
follows that same sequence in the context of relationships. Achievements at
prior stages contain seeds of conflict at the subsequent stages. The model applies
to therapy, teaching, business, friendships, and marriage. Typical of Stiles’s
work, this model has rich conceptual roots. It built upon prior Eriksonian think-
ing, broadening it to other psychological domains.
Verbal Response Modes
Much of Stiles’s early work focused on verbal response modes (VRMs).

The VRM system focuses on the microrelationships that people establish as
they speak. It describes how speakers position themselves with respect to peo-
ple or groups they address, whether they use their own frame of reference or
others’, and how they choose grammatical forms to heighten, soften, or enrich
their intended messages. The main virtue of the VRM system may be that it
allows interpersonal communication to be quantified and empirically studied.
This has proved useful for studying verbal exchanges in therapy. For example,
client and therapist speech could be placed into categories such as questions,
advisements, and interpretations.
Stiles traced the idea of VRMs to a conceptual influence from Jerry
Goodman, who introduced him to six different response modes intended to
be helpful: questions, advisement, interpretation, reflection, disclosure, and
silence. In his book, Describing Talk: A Taxonomy of Verbal Response Modes,
Stiles (1992) recounted his initial attraction:
I was attracted to the response modes at first by the therapeutic power of
Reflections. I was fascinated by the process-facilitating effects of “simply”
repeating a client’s communication, in comparison to, say, the process-
deflecting effects of Questions. Reflections were followed by deeper explo-
ration; Questions were followed by a change in direction. In the tapes of
therapy, in my work as a therapist, and in my own experience of being
listened to, response modes seemed to make a dramatic difference. (p. 1)

Several years later, as an assistant professor, Stiles examined whether certain
response modes were more therapeutic than others. Although he approached
this question with an open mind as a researcher, he personally wondered
whether responses in the client-centered tradition (e.g., empathic reflec-
tions) were especially useful. His research suggested that certain response
modes were not inherently better than others (i.e., did not lead to better
therapy outcomes), but it did lead to the classification of various kinds of
therapist interventions.
VRM-based studies of psychotherapy showed that therapists of different
orientations have dramatically different profiles of verbal interventions. That
is, therapists predominantly rely on verbal response modes that are consistent
with their theoretical orientations (Stiles, 1979b; Stiles, Shapiro, & Firth-
Cozens, 1988). Each theory’s therapeutic recommendations are consistent with
and can be seen as prescribing and proscribing particular response modes. For
example, the Rogerian approach, which focuses on the client’s frame of refer-
ence, would rely on response modes such as Reflection and Acknowledgement
rather than Advisement or Question. As it happens, clients use a similar pro-
file of modesregardless of their therapist’s orientation, with the most prominent
client mode being Disclosure.
Equivalence Paradox and Responsiveness
The finding that VRMs did not directly predict outcome was consistent
with the enigmatic yet common finding of null correlations between types
of interventions and outcomes. These results influenced Stiles’s thinking
about one of the long-standing puzzles in psychotherapy research: the
equivalence paradox. Also known as the Dodo verdict, it refers to the estab-
lished finding of equivalent outcomes for therapies that use vastly different
methods (Luborsky, Singer, & Luborsky, 1975; Stiles, Shapiro, & Elliott,
1986). To help understand this paradox, Stiles articulated the concept of
responsiveness (Stiles, 1988; Stiles, Honos-Webb, & Surko, 1998). Respon-
siveness suggests that therapeutic interventions tend to be delivered to
clients in ways that match their emerging needs on a moment-to-moment
basis. That is, interventions are delivered responsively rather than rigidly
as advised by therapy manuals. Stiles suggested that responsiveness to
clients’ needs rather than the amount of any type of intervention per se may
be driving therapeutic success. For example, the fact that empathic reflec-
tion may generally be helpful does not always mean that more of it will yield
a better outcome (the client may not need more). Explaining outcomes as
driven by the nonlinear, complex patterns in which therapists responsively
meet clients’ emerging needs required qualitative approaches to capture
interactions, timing, and context of interventions. This approach provided

an alternative to the dose–response model, in which therapy is treated like
a drug and analyzed to determine the optimal relationship between number
of sessions and outcome.
Assimilation Model
Stiles’s work with VRMs sensitized him to nuances of clients’ verbal

expression. This sensitivity, and an appreciation for the complex relation-
ship between process and outcome variables, led him to explore common
patterns of therapeutic change. His participation in an ongoing seminar
with Robert Elliott and David Shapiro in Sheffield, England, in 1984–1985
furthered his thinking in this area and led to an early version of the assim-
ilation model. The concept of assimilation can be explained in Piagetian
terms: Experiences are assimilated into schemas—ways of thinking and act-
ing that are developed or modified (accommodation) in order to assimilate
the new experience (Stiles et al., 1990). Assimilation can also be described
using the metaphor of voice (Honos-Webb & Stiles, 1998; Stiles, 1999) to
emphasize that traces of past experiences are active within people. They
seek to be expressed through actions, words, affective states, and so on.
The previously assimilated, interlinked traces of experiences are consid-
ered as a community of voices within the person. Assimilated voices can
be resources—available when needed—whereas unassimilated voices tend
to be the unresolved problematic experiences that often bring people to
therapy.
Difficult-to-assimilate experiences are referred to as problematic voices.
The process of assimilating them into the community is described as building
connections or meaning bridges. A meaning bridge is any sign (e.g., word, image,
gesture) that means the same thing to both the problematic voice and the com-
munity. It is this process of building meaning bridges that allows clients to more
fully experience and accept all parts of themselves and become less psycholog-
ically fragmented.
Eight developmental stages of assimilation have been outlined in the
Assimilation of Problematic Experiences Sequence (APES; Stiles, 2002;
Stiles & Angus, 2001; Stiles et al., 1991). The APES levels are (0) warded
off/dissociated, (1) unwanted thoughts/active avoidance, (2) vague awareness/
emergence, (3) problem statement/clarification, (4) understanding/insight,
(5) application/working through, (6) resourcefulness/problem solution, and
(7) integration/mastery. Both cognitive and affective features characterize
each level. Levels represent anchor points along a continuum. Clients may
enter treatment at any point, and any movement along the continuum is con-
sidered progress.

Stiles’s interest in the assimilation of discrepant, traumatic, or unwanted
parts of the self can be traced to his humanistic, client-centered foundation.
Carl Rogers wrote a great deal about therapists valuing all aspects of clients,
in turn allowing clients to do this for themselves.
The therapist perceives the client’s self as the client has known it, and
accepts it; he perceives the contradictory aspects which have been denied
to awareness and accepts those too as being a part of the client; and both
of these acceptances have in them the same warmth and respect. (Rogers,
1951, p. 41)
Rogers noted that when individuals can come to “own” or “assimilate”
experiences—without denying or distorting them—they feel more free-
dom and unity. And although Stiles would not suggest that client-
centered therapy is the only successful way to assimilate problematic expe-
riences (his research has shown that many therapies are useful in this way),
it certainly helped provide a framework for understanding how change
occurs.
Assimilation analyses have yielded a variety of examples of problem-
atic experiences that were assimilated, to a greater or lesser degree, follow-
ing the pattern described in the APES (for case examples, see Stiles &
Angus, 2001). Each case was different and has confirmed, modified, and elab-
orated aspects of the model; their aggregate offers a substantial basis for
confidence in the model.
Stiles has generously allowed and in fact encouraged his graduate
students to conduct assimilation research in line with their own interests.
He usually refers to the assimilation model as “our theory,” not “my theory.”
His humility and openness have allowed the theory to be applied to fields
outside of psychotherapy. For example, his theory has informed projects
examining immigrants’ adjustment, assimilation of sexual abuse, stages of
rehabilitation of sex offenders, and consultative interventions in organiza-
tion development.
Qualitative Research
Stiles and his research group have applied qualitative methods to study-
ing therapy, particularly with the assimilation model. This work, along with
Stiles’s elaboration of the philosophy and rationale of qualitative approaches,
helped establish qualitative inquiry as a scientific method in its own right
rather than a lesser strategy used for lack of alternatives. Stiles addressed the
issue of methodological rigor by articulating good practice standards (criteria
of reliability and validity) in qualitative research (Stiles, 1993, 2003). Much
of his recent thinking has centered on comparing and contrasting the episte-

mologies of qualitative versus quantitative approaches and promoting the use
of case studies (Stiles, 2005, 2007).
Alliance and Session Evaluations
Stiles’s Session Evaluation Questionnaire (SEQ), a brief, comprehen-

sive questionnaire that can be completed by clients, therapists, and observers,
is frequently used to measure session impact (Stiles, Gordon, & Lani, 2002).
The SEQ measures session depth, smoothness, and postsession mood.
Client–therapist agreement on SEQ ratings is generally weak, reminding us
of the constructed nature of experience and the importance of checking in
with clients about their evaluations.
Stiles has also contributed to the measurement of alliance, one of the
strongest known predictors of therapy outcome. An example of this is his
work on developing and testing the Agnew Relationship Measure (ARM;
Agnew-Davies et al., 1998; Stiles et al., 2002), an alliance questionnaire sim-
ilar to the Working Alliance Inventory (Horvath & Greeberg, 1986, 1989).
Using the ARM, Stiles has articulated the relationship between patterns of
alliance development and outcome (Stiles et al., 2004).
OTHER CONTRIBUTIONS
Stiles has been intimately connected with the Society for Psychother-
apy Research (SPR) since attending his first conference in 1981 in Aspen,
Colorado. In 1980, Al Mahrer invited him to participate in an APA sympo-
sium, “Psychotherapy Process Research: A Preview of the Next Decade.” The
other participants, Clara Hill and Robert Elliott, encouraged him to attend
the next SPR conference. He has collaborated with numerous individuals
from this organization, who have served as a valuable reference group. Stiles
served as program chair for the 28th international annual meeting in 1997 in
Geilo, Norway, and was president for the 1997–1998 year. In 2009, he
received the prestigious Distinguished Research Career Award from SPR.
Stiles helped establish a local area group, Ohio SPR, uniting three centers
of psychotherapy research (Miami University, Ohio University, and Univer-
sity of Toledo) into a consortium. This small, intimate conference—geared
toward grad students—met annually between 2001 and 2007.
Stiles’s affiliation with SPR led to his service as associate editor and then
editor for the organization’s journal, Psychotherapy Research. He has engaged
in editorial duties with his usual sense of quiet commitment and conscientious-
ness, hoping to ensure the integrity of the peer review process he has long val-
ued. At this writing, Stiles is the coeditor of Person-Centered and Experiential
Psychotherapies and associate editor of the British Journal of Clinical Psychology.

STILES’S LEGACY
Stiles’s program of psychotherapy research has centered on several areas:

VRMs, the assimilation model, process–outcome relationships, and qualita-
tive methodology. Perhaps the broadest theme in all of his work is under-
standing human experience through evolving and ever-refining theoretical
accounts. Stiles’s deep and genuine interest in people (what they think, how
they feel, where this comes from) is evident in everything he does: what he
researches, how he supervises clinical trainees, how he mentors graduate stu-
dents, and how he works with colleagues. He continues to challenge himself
and others, asking difficult questions (What is truth? How will we recognize
it? How does talking help?). His attempts to answer these questions have
improved our understanding of whether and how psychotherapy helps and
have inspired others to be just as curious.
REFERENCES
Agnew-Davies, R., Stiles, W. B., Hardy, G. E., Barkham, M., & Shapiro, D. A.
(1998). Alliance structure assessed by the Agnew Relationship Measure (ARM).
British Journal of Clinical Psychology, 37, 155–172.
Honos-Webb, L., & Stiles, W. B. (1998). Reformulation of assimilation analysis in
terms of voices. Psychotherapy, 35, 23–33. doi:10.1037/h0087682
Horvath, A. O., & Greenberg, L. S. (1986). The development of the Working
Alliance Inventory. In L. S. Greenberg & W. M. Pinsof (Eds.), The psycho-
therapeutic process: A research handbook (pp. 529–56). New York, NY: Guil-
ford Press.
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the
Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233.
Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psycho-
therapies: Is it true that “Everyone has won and all must have prizes”? Archives
of General Psychiatry, 32, 995–1008.
Stiles, W. B. (1979a). Psychotherapy recapitulates ontogeny: The epigenesis of inten-
sive interpersonal relationships. Psychotherapy: Theory, Research, and Practice,
16, 391–404. doi:10.1037/h0088365
Stiles, W. B. (1979b). Verbal response modes and psychotherapeutic technique. Psy-
chiatry, 42, 49–62.
Stiles, W. B. (1981). Science, experience, and truth: A conversation with myself.
Teaching of Psychology, 8, 227–230. doi:10.1207/s15328023top0804_11
Stiles, W. B. (1988). Psychotherapy process-outcome correlations may be mislead-
ing. Psychotherapy, 25, 27–35. doi:10.1037/h0085320

Stiles, W. B. (1992). Describing talk: A taxonomy of verbal response modes. Newbury
Park, CA: Sage.
Stiles, W. B. (1993). Quality control in qualitative research. Clinical Psychology
Review, 13, 593–618. doi:10.1016/0272-7358(93)90048-Q
Stiles, W. B. (1999). Signs and voices in psychotherapy. Psychotherapy Research, 9,
1–21. doi:10.1093/ptr/9.1.1
Stiles, W. B. (2002). Assimilation of problematic experiences. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Therapist contributions and responsiveness to
patients (pp. 357–365). New York, NY: Oxford University Press.
Stiles, W. B. (2003). Qualitative research: Evaluating the process and the product.
In S. P. Llewelyn & P. Kennedy (Eds.), Handbook of clinical health psychology
(pp. 477–499). London, England: Wiley. doi:10.1002/0470013389.ch24
Stiles, W. B. (2005). Case studies. In J. C. Norcross, L. E. Beutler, & R. F. Levant
(Eds.), Evidence-based practices in mental health: Debate and dialogue on the fun-
damental questions (pp. 57–64). Washington, DC: American Psychological
Association.
Stiles, W. B. (2006). Numbers can be enriching. New Ideas in Psychology, 24,
252–262. doi:10.1016/j.newideapsych.2006.10.003
Stiles, W. B. (2007). Theory-building case studies of counselling and psycho-
therapy. Counselling & Psychotherapy Research, 7, 122–127. doi:10.1080/
14733140701356742
Stiles, W. B., Agnew-Davies, R., Barkham, M., Culverwell, A., Goldfried, M. R.,
Halstead, J., . . . Shapiro, D. A. (2002). Convergent validity of the Agnew Rela-
tionship Measure and the Working Alliance Inventory. Psychological Assess-
ment, 14, 209–220. doi:10.1037/1040-3590.14.2.209
Stiles, W. B., & Angus, L. (2001). Qualitative research on clients’ assimilation of
problematic experiences in psychotherapy. In J. Frommer & D. L. Rennie (Eds),
Qualitative psychotherapy research: Methods and methodology (pp. 112–127).
Lengerich, Germany: Pabst Science Publishers.
Stiles, W. B., Elliott, R., Llewelyn, S. P., Firth-Cozens, J. A., Margison, F. R.,
Shapiro, D. A., & Hardy, G. (1990). Assimilation of problematic experiences
by clients in psychotherapy. Psychotherapy, 27, 411–420. doi:10.1037/0033-
3204.27.3.411
Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies,
R., . . . Barkham, M. (2004). Patterns of alliance development and the rupture-
repair hypothesis: Are productive relationships U-shaped or V-shaped? Journal
of Counseling Psychology, 51, 81–92. doi:10.1037/0022-0167.51.1.81
Stiles, W. B., Gordon, L. E., & Lani, J. A. (2002). Session evaluation and the Ses-
sion Evaluation Questionnaire. In G. S. Tryon (Ed.), Counseling based on process
research: Applying what we know (pp. 325–343). Boston, MA: Allyn & Bacon.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psycho-
therapy. Clinical Psychology: Science and Practice, 5, 439–458.

Stiles, W. B., Morrison, L. A., Haw, S. K., Harper, H., Shapiro, D. A., & Firth-
Cozens, J. (1991). Longitudinal study of assimilation in exploratory psycho-
therapy. Psychotherapy, 28, 195–206. doi:10.1037/0033-3204.28.2.195
Stiles, W. B., Shapiro, D. A., & Elliott, R. (1986). Are all psychotherapies equivalent?
Stiles, W. B., Shapiro, D. A., & Firth-Cozens, J. A. (1988). Verbal response mode use
in contrasting psychotherapies: A within-subjects comparison. Journal of Consult-

IV
WHAT WORKS FOR WHOM?
26
SOL L. GARFIELD: A PIONEER
IN BRINGING SCIENCE
TO CLINICAL PSYCHOLOGY
LARRY E. BEUTLER AND ANNE D. SIMONS
The death of Sol Garfield in August of 2004 portended the end of an era
in psychotherapy and clinical psychology. Sol Garfield was one of a handful of
psychologists, largely educated in the years before and during World War II,
who established clinical psychology as both a health profession and a science.
With professional colleagues like Allen Bergin, Hans Strupp, Lester Luborsky,
Kenneth I. Howard, Morris Parloff, and David Orlinsky, Sol worked to estab-
lish recognition for psychotherapy research as a legitimate scientific discipline
and thereby firmly established the scientist–professional model of training and
practice as an ideal for clinical psychology.
Facing the daunting task of challenging the giants of psychodynamic the-
ories in the middle and late 20th century, Sol Garfield became a controversial
man. Although often seen as a “kindly curmudgeon” (Beutler, 1998), he was
vocally and notably in disagreement with many of the developments in clini-
cal psychology and psychotherapy research that dominated the discipline in
the 20th and early 21st centuries. He was a vocal critic of randomized clinical
trials as the gold standard for determining psychotherapy’s effects, of process
research without first obtaining strong evidence of beneficial outcome, of the
PsyD degree and the accompanying professionalization of psychology, of
prescriptive authority for psychologists, and of the empirically unsupported
309
practice of psychoanalysis. These issues troubled Garfield immensely, and he
used the spoken and written word to try to hold clinical psychology on a course
that would be true to its scientific foundations, as well as to keep the Society
for Psychotherapy Research (SPR), a group that he cofounded, to its commit-
ment to students and scholarship. Garfield viewed clinical psychology as “sci-
entifically oriented” with a mission for “providing services to all segments of
the public without a dominant interest in our own economic aggrandizement”
(Garfield, 1991a; p. 119). His career was devoted to establishing this ideal, and
it served as a model, for those of us who followed, of what we might become
if we adopted his view of a worthy and accountable clinical psychology.
MAJOR CONTRIBUTIONS
During his career, which spanned more than 60 years, Sol Garfield pub-
lished nearly 200 articles, chapters, and books. These contributions had an
immense impact on the field, as noted by the extensive list of honors and
awards that Garfield received during this time. However, none of his contri-
butions match or exceed that of editing and publishing four volumes of The
Handbook of Psychotherapy and Behavior Change, with his good friend and col-
league Allen Bergin. The first of these volumes appeared in 1971 (Bergin &
Garfield, 1971) and rapidly became the psychotherapy researcher’s and clin-
ical psychologist’s bible. Among the most widely cited books in American
psychology, the Handbook set the bar of evidence for effective practice. It left
an indelible mark on two generations of clinical psychologists and researchers;
and it became the definitive reference for the information and relationships
“factually embedded” in scientific methods. Indeed, the Handbook ushered
in the age of accountability in clinical psychology, expressed best by Garfield’s
(1994) words: “Let scientific evaluation make determinations about what
treatments, provided by whom, are best applied to what types of client
problems.”
Sol Garfield provided some of the earliest work on the types and numbers
of psychotherapies being practiced. The context for this work was the very rapid
surge in different variants of psychotherapy dating from the 1960s. Surveying
so many different therapies, Garfield and his longtime colleague at Washington
University, Richard Kurtz, reported very interesting data on how therapists
described their work, finding a large number who espoused eclecticism, reject-
ing any one particular theoretical orientation in favor of picking and choosing
from a number of models (Garfield & Kurtz, 1977). Garfield’s Psychotherapy: An
Eclectic Approach (1980/1995) provided a way forward, advocating a form of
eclectic treatment built on optimizing the common client, therapist, and inter-
vention characteristics of all effective treatments (Garfield, 1987, 2000).
310 BEUTLER AND SIMONS

Through his work, Garfield established his reputation as a leading common
factors theorist, arguing that these factors, however defined and operational-
ized, were more responsible for good outcomes in psychotherapy than any of the
specific factors unique to a given model of psychotherapy. This position con-
tinues to generate considerable attention and research activity (Wampold,
2001) and a debate that one can only speculate that Garfield would welcome.
Garfield was also a strong contributor to the lively debate on the merits of treat-
ment manuals and the trend toward the identification of empirically supported
treatments for different disorders (Garfield, 1996, 1998).
Garfield was very interested in client variables in psychotherapy and lit-
erally wrote the book on this area of research in his chapters for the different
editions of the Handbook of Psychotherapy and Behavior Change (Bergin &
Garfield, 1971, 1978, 1994; Garfield & Bergin, 1986). While he acknowledged
that predictions regarding continuation and outcome based solely on client
variables are unlikely to be successful, he identified some early predictors of
continuation and benefit such as expectations, a client variable that contin-
ues to be the focus of contemporary psychotherapy research as they related to
different aspects of therapy, particularly premature termination (Greenberg,
Constantino, & Bruce, 2006).
Garfield’s other research cut across a large number of topics, including the
use of the Rorschach and the Thematic Apperception Test, measurement of
performance among minority adolescents, intellectual measurement, clinical
training, usefulness of psychological reports, classification and identification of
those with mental retardation, drug effects on performance of patients with seri-
ous mental illness, and selection and training of aircraft pilots.
These were his numerous and extensive formal contributions, but his
informal ones—the mentoring that he did for his students and colleagues—
surely surpassed these sterile (by comparison) expressions of facts.
EARLY BEGINNINGS
Sol Garfield’s acceptance of the mantles conferred with the various roles
that became clinical psychology came in stages, and not always by his election
and choice. He was virtually driven into psychology by the anti-Semitic atti-
tudes of the time. However, Garfield developed his concern for people long
before he obtained his formal education. While still in high school and college,
he learned by experiencing the trials of helping to support his family—his par-
ents and a younger sister—during the Great Depression. He gained an appreci-
ation for struggle and pain by observing his father’s efforts to overcome the
financial failure of his grocery business and rise above it; he learned patience
and empathy as one of few non-Black residents in his Chicago neighborhood;
SOL L. GARFIELD 311

and he learned the pain of rejection and the frustration of discrimination by
experiencing the anti-Semitism of pre–World War II Chicago.
Born in 1918, growing up during the Great Depression, and educated dur-
ing the war years, Sol struggled to help his family survive. When the failing
economy of the early 1930s forced his father to give up his grocery store just as
Sol was entering his freshman year at the University of Wisconsin, Sol came
home to help his family. While he attended the Central YMCA College in
downtown Chicago, this interest in psychology was piqued by the results of the
Strong Vocational Interest Inventory. Taking this test helped move him to
change career directions from prelaw to education. He wanted to be a second-
ary school teacher, but he would find that this role would elude him.
In a real way, Garfield’s career in psychology was necessitated by his
inability, as a young Jewish man, to obtain work in the teaching profession.
When he failed to find a job after obtaining his baccalaureate degree from
Northwestern University in 1938, he enrolled in graduate school to better pre-
pare himself and improve his chances. But he subsequently found that an MA
in education was no help, either—his ethnicity again precluded his being able
to find work as a teacher or guidance counselor. Although he was discouraged
by some of his faculty from entering the PhD program, circumstances and the
persuasion of Paul Witty, a distinguished faculty member in the Department
of Education and Guidance, contrived to help him earn the PhD. Although
his PhD degree was in education and guidance, over half of the courses he took
were in the Department of Psychology, and his graduate committee consisted
of more psychologists than of education faculty. He was drawn to psychology,
but it still took the intervention of chance and outside forces finally to settle
his career choice. Indeed, it was the U.S. military that made him an official
psychologist.
Garfield was inducted into the U.S. Army in December of 1942, where
he was assigned to an infantry division. Enter again the constraint of anti-
Semitism—he was denied entry to officer candidate school and assigned to
the adjutant general’s personnel consultant assistant school. His appeal to be
reassigned was denied. He was trained and assigned to the psychology section.
For the remainder of his service career and for the rest of his life, he was offi-
cially a psychologist.
Garfield served in a variety of locations while in the service. His first
experiences as a clinical psychologist were at the Third Service Command in
Baltimore, where he served on the neuropsychiatry unit, under the direction
of the chief of service, Dr. Henry Brosin, a psychoanalyst and psychiatrist.
With the encouragement of Brosin and several other psychiatric colleagues,
Garfield learned about psychopathology, did many intake evaluations, and
began conducting psychotherapy.

The war ended in 1945, and at the end of that year, Garfield married
Amy Nussbaum, whom he described, with his inimitable sense of humor, as
being “properly appreciative of my talents” (Garfield, 1991a; p. 104). He was
discharged in 1946 and began work at the Mendota, Wisconsin, Veterans
Hospital. It was there that Garfield’s interest in teaching and training devel-
oped. He initiated both practicum and internship programs while in the
Mendota VA and fostered the role of psychologists as psychotherapists.
Garfield left the Mendota VA after 14 months and entered academia as
an assistant professor of psychology at the University of Connecticut, where
he established a PhD program in clinical psychology. He left after less than
2 years to return to the VA, this time in Milwaukee, Wisconsin. Garfield’s
career in the following years moved back and forth between VA programs and
academia as his interests in research were reawakened. Throughout, the red
thread that defined his career never unravelled—the integration of research,
education, and practice.
Three positions accounted for 28 years of Garfield’s career, the longest
lasting being his tenure at Washington University in St. Louis, where he ulti-
mately retired as professor emeritus. His years (1957–1963) at the University of
Nebraska College of Medicine cemented his commitment to the role of
research in practice and furthered his commitment to a psychology that was dis-
tinguished from psychiatry. His years at Columbia University Teachers College
(1964–1970) saw his career flourish as he achieved wide recognition for his
research and scholarly writing on psychotherapy. His time at Washington
University was a time of consolidation during which he finalized his stance as
an eclectic psychotherapist and came to enjoy the fruits of his efforts. Here,
Garfield’s wisdom was recognized in the scholarly and wise contributions for
which he ultimately was best known—the several editions of The Handbook of
Psychotherapy and Behavior Change.
ACCOMPLISHMENTS
Sol Garfield’s life reflects much of the American dream in the postwar
years. He came from humble beginnings, as the child of immigrant Polish Jews
who sought in America an opportunity for freedom from oppression and big-
otry. The fact that this dream was not realized, given that Garfield experienced
some of the anti-Semitism in Middle America that his parents had sought to
escape in Poland, makes his achievements all the more impressive.
In Sol’s self-reflections, he noted progressive dissatisfaction with his col-
leagues’ psychoanalytic traditions and their authoritative, but meaningless,
formulations of patients’ problems. He also reported some satisfaction with the
SOL L. GARFIELD 313

power of his own experience as an emerging psychotherapist who tried new
things and with the evolution of his identity as an eclectic psychotherapist. At
the Milwaukee Veterans Hospital, Garfield began to notice that different
patients responded to different styles of intervention. In Milwaukee and after,
he began to identify himself more and more as a psychotherapist and at the
same time became more and more convinced that research was the answer to
the question of “what worked.” Indeed, it was his shift in research away from
assessment and prediction of human performance and toward factors that pre-
dicted dropout that confirmed his reputation as one of the leading proponents
of common factors approaches to psychotherapy integration (Garfield, 1991b;
1997). However, it was only a gradual development of interest and observa-
tion that led Garfield to become firmly and finally convinced that the many
practices then in vogue could not be supported by research and to develop
the conviction that empirical evidence should be the basis for practice. He
wryly observed that few psychotherapists ever questioned the efficacy of their
own psychotherapy practices, although they had doubts about the therapy of
others (Garfield, 1994).
In 1952, when he was in charge of the training unit in the Downey,
Illinois, VA, Garfield and a colleague conducted a study on outcomes of 1,216
patients who had been treated in an outpatient mental hygiene clinic (Garfield
& Kurz, 1952). The results demonstrated a remarkable disparity between the
perception of therapists who reported conducting “long-term psychotherapy”
on their patients and the remarkably brief therapy that patients were actually
receiving. Most patients received no more than 10 sessions of treatment, and
fewer than 10% received 25 or more sessions. Early terminations were ignored,
forgotten, overlooked, or denied by therapists.
The results of this study caught Garfield’s imagination. While he contin-
ued his research on measurement and diagnosis, he was increasingly interested
in how psychotherapy worked and failed to work. He published two studies on
premature dropout (Garfield & Affleck, 1959, 1961) and then began to refine
his focus on patient expectations in following years (Garfield, 1963; Garfield,
Affleck, & Muffly, 1963; Garfield & Wolpin, 1963).
OTHER CONTRIBUTIONS
From 1963 to 1965, Garfield served on the advisory committee for a

conference on the professional preparation of clinical psychologists for the
American Psychological Association (APA), publishing his first article on
training and psychology’s search for identity (Garfield, 1966). A year later, he
and colleagues (Garfield, Bergin, & Thompson, 1967) published the results of
the Chicago Conference on Training in Clinical Psychology.

Garfield’s contributions were not restricted to publications and research.
He reported with some pride, his selection in 1959 to be the secretary–treasurer
of APA’s Division of Clinical Psychology (1960–1963; Garfield, 1991a). He
later rose to serve as president of that organization (1965) and received this divi-
sion’s Distinguished Contributions Award. Among his many leadership roles, he
also served as president of the Illinois Psychological Association in 1958; presi-
dent of SPR in 1976–1977; and president of the Division of Clinical Psychology
of the American Psychological Association (APA) in 1965. He served at least
three terms as a member of the Council of Representatives of APA.
Among his many accolades, he was a recipient of the Distinguished
Contributions to Knowledge Award from APA; the Distinguished Scientist
Award from the Section on Clinical Psychology as an Experimental–
Behavioral Science (Division of Clinical Psychology, APA); the Distinguished
Research Career Award from SPR; and the Award for Outstanding Contri-
butions to Clinical Training from the Council of University Directors of
Clinical Psychology. However, of all his professional contributions, Garfield
expressed special pleasure (Garfield, 1991a) at being asked by APA to serve on
the advisory committee for a conference on professional preparation of clinical
psychologists, which was focused on the development of practicum and intern-
ship experiences. This position ranked along with the awards and recognition
that he received from the membership of SPR, which he had cofounded in
1962, for his work on the Handbook with his friend Allen Bergin, and for his
work as editor of the Journal of Consulting and Clinical Psychology (1979–1984).
INFLUENCES
There were many who influenced Garfield throughout the years. Cer-
tainly, he was close to his parents, and after his marriage sought wisdom and
support from his wife, Amy. His early mentor, Paul Witty, helped set him in a
direction of research interest and education, a direction further encouraged by
Professor A. R. Gilliland, who was then chair of the Department of Psychology
at Northwestern University. In his postgraduate years, others came to influence
him strongly. The list is endless, but certainly Ralph Heine, Craig Affleck,
Allen Bergin, Jerome Frank, Leonard Eron, and his senior colleagues and coor-
ganizers of SPR were among them. He spoke of these people often, both in his
personal communications with colleagues (present authors among them) and
in his personal reflective writings (Garfield, 1991a; 2000).
Sol Garfield was a mentor to many. He published with a large cadre of stu-
dents, the last of whom is a coauthor of this chapter (Simons). Many of his pre-
vious students are now involved in clinical psychology training in various
settings; all remember his insistence on empirical support for clinical work and
SOL L. GARFIELD 315

have commented on how this insistence could be viewed as the precursor to the
current zeitgeist of empirically supported treatments and evidence-based prac-
tice. His strength as a mentor also extended generously to junior colleagues,
whom he encouraged, for whom he served as a model, and to whom he con-
stantly gave of his wit and wisdom while opening doors and providing advice.
CONCLUSION
Sol Garfield is described in the subtitle of this chapter as “a pioneer in

bringing science to clinical psychology.” There can be no doubt that he blazed
this trail at a time when it was difficult and unpopular to do so. Indeed, the zeit-
geist of the time held that the mysteries of psychotherapy would not yield to
the scientific method. Only a man of Sol’s intelligence, courage, and convic-
tion could succeed in truly changing the course and face of clinical psychology.
The issues with which he grappled—What are the mechanisms of change in
psychotherapy? How can we assess outcomes in psychotherapy? What are the
client variables that influence clients to enter, continue in, and benefit from
psychotherapy?—remain current today.
REFERENCES
Bergin, A., Garfield, S., & Thompson, A. (1967). The Chicago Conference on Clinical
Training and Clinical Psychology at Teachers College. American Psychologist, 22,
307–316.
Beutler, L. E. (May, 1998). A tribute to Sol Garfield. Unpublished paper presented to
the faculty and students at Washington University, St. Louis, MO.
Garfield, S. L. (1963). A note on patients’ reasons for terminating therapy. Psychological
Reports, 13(1), 38–42.
Garfield, S. L. (1966). Clinical psychology and the search for identity. American
Psychologist, 21, 353–362. doi:10.1037/h0023529
Garfield, S. L. (1971). Research on client variables in psychotherapy. In A.E. Bergin
& S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change: An empir-
ical analysis (1st ed., pp. 271–298). New York, NY: Wiley.
Garfield, S. L. (1978). Research on client variables in psychotherapy. In A. E. Bergin
& S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (2nd ed.,
Garfield, S. L. (1986). Research on client variables in psychotherapy. In S. L. Garfield
& A. E. Bergin (Eds.) Handbook of psychotherapy and behavior change (3rd ed.,
Garfield, S. L. (1987). Towards a scientifically oriented eclecticism. Scandinavian
Journal of Behavior Therapy, 16(3), 95–109.

Garfield, S. L. (1991a). A career in clinical psychology. In C. E. Walker (Ed.), A his-
tory of clinical psychology in autobiography (pp. 87–123). Pacific Grove, CA: Brooks/
Cole.
Garfield, S. L. (1991b). Psychotherapy models and outcome research. American
Psychologist, 46, 1350–1351. doi:10.1037/0003-066X.46.12.1350
Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin
& S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed.,
Garfield, S. L. (1995). Psychotherapy: An eclectic-integrative approach (2nd ed.). New
York, NY: Wiley. Originally published in 1980.
Garfield, S. L. (1996). Some problems associated with “validated” forms of psychother-
apy. Clinical Psychology: Science and Practice, 3, 218–229.
Garfield, S. L. (1997). Brief psychotherapy: The role of common and specific factors.
Clinical Psychology & Psychotherapy, 4, 217–225. doi:10.1002/(SICI)1099-
0879(199712)4:4<217::AID-CPP134>3.0.CO;2-Y
Garfield, S. L. (1998). Some comments on empirically supported psychological
treatments. Journal of Consulting and Clinical Psychology, 66, 121–125. doi:10.
1037/0022-006X.66.1.121
Garfield, S. L. (2000). Eclecticism and integration: A personal retrospective view.
Journal of Psychotherapy Integration, 10, 341–355.
Garfield, S. L., & Affleck, D. C. (1959). An appraisal of duration of stay in outpatient
psychotherapy. Journal of Nervous and Mental Disease, 129, 492–498. doi:10.
1097/00005053-195911000-00010
Garfield, S. L., & Affleck, D. C. (1961). Therapists’ judgments concerning patients
considered for psychotherapy. Journal of Consulting Psychology, 25, 505–509.
doi:10.1037/h0046098
Garfield, S. L., Affleck, D. D., & Muffly, R. (1963). A study of psychotherapy inter-
action and continuation in psychotherapy. Journal of Clinical Psychology, 19,
473–478. doi:10.1002/1097-4679(196310)19:4<473::AID-JCLP2270190428>3.
0.CO;2-3
Garfield, S. L., & Kurz, M. (1952). Evaluation of treatment and related procedures
in 1,216 cases referred to a mental hygiene clinic. Psychiatric Quarterly, 26(1),
414–424. doi:10.1007/BF01568477
Garfield, S. L., & Kurtz, R. (1977). A study of eclectic views. Journal of Consulting and
Garfield, S. L., & Wolpin, M. (1963). Expectations regarding psychotherapy. Journal
of Nervous and Mental Disease, 137, 353–362. doi:10.1097/00005053-196310000-
00007
Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are expectations still rel-
evant for psychotherapy process and outcome? Clinical Psychology Review, 26,
657–678. doi:10.1016/j.cpr.2005.03.002
Wampold, B. E. (2001). The great psychotherapy debate. Mahwah, NJ: Erlbaum.
SOL L. GARFIELD 317

27
LARRY E. BEUTLER: A MATTER
OF PRINCIPLES
PAULO P. P. MACHADO, HÉCTOR FERNÁNDEZ-ÁLVAREZ,
AND JOHN F. CLARKIN
Larry E. Beutler has devoted his entire academic career to investigating

and unraveling the complexity of change in psychotherapy. By doing so, he
has systematically and strategically challenged the field of psychotherapeutic
research to abandon the theoretical trenches and openly embark on a quest
for the principles underlying the therapeutic endeavor. As a result, he has
made significant contributions to our understanding of which treatment
works for which individual and how therapists should select their goals and
therapeutic strategies on the basis of patient characteristics rather than the-
oretical orientation or traditional diagnostic categories.
MAJOR CONTRIBUTIONS
It is difficult to assess the impact of Larry Beutler’s countless contribu-

tions to the field of psychotherapy research. Those who have been lucky
enough to have worked, collaborate with, or even chat with him are most
probably impressed with his strong motivation for scientific discovery, as
well his quest for how to best serve those in need of psychological services.
Several areas of extensive and intense focus and concentration stand out,
319
nonetheless, and these include psychotherapy research and systematic treat-
ment selection. These two areas of concentration reflect his early career focus
on both the art of helping others and a scientific approach to that endeavor.
The search for specific factors that would maximize treatment matching
to a patient’s individual characteristics was present in most of his scientific
production and research projects, and it will probably become his most sig-
nificant contribution to the field of psychotherapy research. Illustrative
examples of this long-term commitment are the seminal book published with
John Clarkin (Beutler & Clarkin, 1990) and later with John Clarkin and
Bruce Bongar (Beutler, Clarkin, & Bongar, 2000) on systematic treatment
selection and his research projects on the treatment of depression (Beutler
et al., 1991), alcoholism (Beutler et al., 1993), and treatment matching
(Beutler, Moleiro, & Talebi, 2002), and several papers in which he challenged
the field to find and test principles that cut across theoretical orientation
and perspectives and helped develop optimal interventions adapted to the
individual characteristics of each patient.
EARLY BEGINNINGS
Larry E. Beutler was born on February 14, 1941, in a small private clinic
in Logan, Utah. He was the younger of two children. After the bombing of
Pearl Harbor, the family moved to San Francisco, where his father briefly
worked in the shipyards. From there, they moved to Arizona and then back
to Logan. His father continued to work in construction, taking the jobs he
could find and farming with his brothers, as well. The period 1943–1944, as
the war continued, was particularly hard for the family, with several severe
losses over those 12 months. His step-grandmother died, his uncle was killed
in the Battle of Okinawa, and then finally came the death of Beutler’s mother
from rheumatic heart disease. After that last loss, Larry and his sister were
shuffled among various relatives, coming to rest with his aunt. They stayed with
her for about a year, until his father remarried. The new family then moved
back into one of the family dwellings, a basement house, a type of dwelling
common at the time. They then moved to Ucon, Idaho, about 150 miles
away, and lived in a one-room cabin while his father built a house for them.
By then Larry was 5 years old, and his career as a cowboy was well developed in
his head. All told, during the first 6 years of his life, he lived in eight different
houses, four different states, and with four different families. Remembering
this, Beutler commented, “No wonder I could never stand being in one place
for a prolonged period of time.”
During his early teenage years, which were marked by more family
moves, illness, and separation, Beutler pursued his interests as a cowboy and
320 MACHADO, FERNÁNDEZ-ÁLVAREZ, AND CLARKIN

horse trainer, taking summer jobs in Canada and Utah. After high school,
where he graduated without distinction, he attended Ricks College, in Rexburg,
Idaho (about 30 miles away), for 1 year before accepting an appointment as
a Mormon missionary in North Carolina and Virginia in 1961.
Upon his return from North Carolina in September of 1963, Beutler
discovered that his father had arranged for his marriage with a young
woman. They married 4 months later, and he went back to school at Ricks
College while working nights to support his new family. He graduated in
sociology in 1963 and transferred to Utah State University. By that point
Larry Beutler had had four different majors, but his interest had been piqued
in psychology, and he was accepted into the BS program in psychology at
Utah State.
At the beginning of his academic career, Beutler was drawn to a com-
bination of social studies and more hard-core scientific studies such as
mathematics and chemistry. His eclectic interests had led to a major in
psychology and minors in sociology and business by by the time he graduated
from Utah State University in 1965. He entered a master’s program at Utah
State while he applied to doctoral programs, having decided firmly by then
that he wanted to get a PhD in clinical psychology and go into private
practice. He earned a research fellowship from the university and was surprised
by the end of the year that he was accepted into several graduate schools.
He chose the University of Nebraska, and he and his wife embarked on
an adventure away from family and church. He entered the University of
Nebraska–Lincoln PhD program in the fall of 1966 and completed it in three
and a half years, including a one-year internship at Norfolk State Hospital
and Regional Center. The experiences with his dissertation at the University
of Nebraska influenced him to become a scientist–practitioner, and his career
has been shaped around that model. His advisor, Dr. James K. Cole, who had
been a student of Carl Rogers, influenced him in pursuing an academic career.
After completing his degree, Beutler moved to North Carolina, where
he accepted a job at Highland Hospital, which was then a Division of Duke
University Medical Center. Here his career began taking off under the tutelage
of Dr. Dale T. Johnson, and within a year he was offered the job of director
of research. He found that he was quite good at getting things published.
His success got him introduced to Sol Garfield, who was then the editor of
the Journal of Consulting Psychology (now the Journal of Consulting and Clinical
Psychology). Garfield introduced Beutler to the Society for Psychotherapy
Research (SPR) and later invited him to be on the review board of that journal.
Garfield assumed and retained the role of Larry’s mentor during the next several
years and stimulated his career in psychotherapy research. His dissertation,
a predictor of a career-long focus, had been on psychotherapist–patient
matching.
LARRY E. BEUTLER 321

These early academic areas of concentration suggest a combination of
scientific and mathematical skills combined with a keen interest in helping
others through counseling and psychotherapy. This dual focus on the art of
psychotherapy and the awareness of and application of scientific methods
would characterize his pursuits for many years to come.
ACCOMPLISHMENTS
Larry Beutler’s main research always orbited around the development

and testing of decisional models for matching specific psychotherapy proce-
dures and formats with patient characteristics. His work focused on defining
empirically based and cross-theoretical guidelines for treatment, matching
interventions to various extradiagnostic patient qualities.
The energy and zeal that Beutler has brought to his research in psychol-
ogy, like the breadth and productivity of that research, are extraordinary.
He is the author of about 400 scientific papers and chapters and is the author,
editor, or coauthor of more than 20 books on psychotherapy, assessment, and
psychopathology. These works have explored multiple disciplines, including
social psychology, the psychology of religion, chemical abuse, forensic
assessment, childhood sexual abuse, sleep, depression, sexual disorders, rape,
victimization of women, and various aspects of psychotherapy. His voracious
appetite for knowledge about the human condition and its sufferings and
possible ameliorations seems unlimited. Beutler has tended always to trust
more in data than in theoretical arguments, and early in his academic career
he was drawn to the exploration of the specific ingredients, or techniques,
that were responsible for client change in psychotherapy.
Curiously, it was Sol Garfield’s rejection of one of his articles, in the late
1970s, that made Beutler rethink what he was doing and turn his attention to
the relationship between process and outcome in psychotherapy, as a function
of the actions of the therapist. Years later, his attention returned to the issue
of matching, now captured within the broader domain of integrating inter-
ventions, relationship factors, participant factors, and context. However,
that rejected article, eventually published in 1979, was where this interest in
integration began.
In this early article, titled “Toward Specific Psychological Therapies for
Specific Conditions” (1979), Beutler laid the foundation for his career-long
quest. Starting with the observation that psychotherapy research had been
unable to clarify the idea that specific therapies would be most efficacious
with specific disorders, Beutler took the position that traditional studies had
always looked at main effects, ignoring potential interactions between patient
characteristics and treatment. He offered a “speculative model for predicting

deferential rates of therapeutic change” (p. 882). This model was based not
solely on theoretical grounds but also on a careful review of the empirical lit-
erature available at the time. Starting with potential patient and symptom
dimensions, specifically, symptom complexity, patient’s defensive style and
reactance, Beutler analyzed 52 comparative psychotherapy studies, looking
for evidence of relationship between these dimensions and treatment outcome.
Revisiting these concerns, Beutler, now editor of the journal that had
initially rejected his article, published another one, ironically titled “Have
All Won and Must All Have Prizes? Revisiting Luborsky et al.’s Verdict”
(Beutler, 1991). In this article, he again claimed that although psychotherapy
research failed to find significant differences between treatment approaches,
it would be premature to stop searching for differential effects. More than
10 years later, the number of available treatment brands had risen from close
to 130 to more than 300, and researchers as well as clinicians struggled to find
sound clinical decision procedures. Again Beutler’s challenge to the field was
to abandon theoretical labels and look for specific ingredients in treatments
that could account for change and, most important, would interact with specific
patient personal characteristics to explain differential effects that were lost when
attention and resources were channeled to look for main effects of treatment.
Given the herculean task of exploring all possible interactions between patient,
therapist, and treatment variables, Beutler suggested the need for consensual
models to guide the search for variables that would mediate treatment effect
on outcome, making a strong argument for the development of “systematic
eclectic models of treatment application” (Beutler, 1991, p. 231).
In his professional work, Beutler was also convinced that the work of
the clinical psychologist (in the assessment and treatment of patients) should
be guided by the application of research results in a systematic way. His book
Eclectic Psychotherapy: A Systematic Approach (1983) was a manifestation of
this effort. At about this same time, a similar book on an organized approach
to the selection of the most optimal psychotherapy for the individual patient
emerged from a medical and psychiatric setting. This book was Differential
Therapeutics in Psychiatry (1984) by Alan Frances, John Clarkin, and Samuel
Perry. Through contacts at SPR and other professional forums, Beutler and
Clarkin combined to further explore the application of research results to
principles and guidelines for the selection of treatment in clinical settings.
This collaboration eventually led to the publication of another important
book, Systematic Treatment Selection: Toward Targeted Therapeutic Interventions
(Beutler & Clarkin, 1990). Later, joined by Bruce Bongar, they decided to
focus the concepts of systematic treatment selection on the treatment of the
depressed patient. In Guidelines for the Systematic Treatment of the Depressed
Patient (Beutler, Clarkin, & Bongar, 2000) they presented guidelines in the
form of hypotheses about the treatment of depressed individuals that they

explored with the existing empirical information. The resulting guidelines
were not limited to any one theory of the psychopathology of depression
or any one school of psychotherapy but, rather, attempted to incorporate
existing data. With an exhaustive review of the empirical literature, two
levels of guidelines were generated. The basic guidelines could be applied
independently of the therapist and used routinely by health care managers.
In contrast, the optimal guidelines were more detailed and involved training and
monitoring of the practicing clinician. The resulting guidelines incorporated
both significant patient characteristics and corresponding aspects of treatment
that had been investigated empirically. Thus, an exhaustive review of the
literature on the depressed patient yielded six patient variables: functional
impairment, subjective distress, social support, problem complexity and
chronicity, reactance/resistance, and major coping styles. These patient relevant
variables, assessed with the appropriate interview and instrumental assess-
ment, were then matched to treatment variables to generate the basic and
optimal treatment guidelines.
The resulting guidelines were nuanced and tailored to the individual
patient, on the basis not only of the diagnosis of depression but also of the six
patient variables emerging from the data. In addition, the guidelines went
beyond treatment school labels to research-generated aspects of treatment
delivery that are relevant across schools of information. These guidelines
differed from those generated by official organizations, like the American
Psychological Association (APA) and the American Psychiatric Association,
in their thorough empirical basis and matching of multiple patient and treat-
ment characteristics.
Beutler expressed his concerns with translating research findings to
clinical practice in a talk titled “David and Goliath: When Psychotherapy
Research Meets Health-Care Delivery Systems,” the Rosalee G. Weiss
lecture at the 1999 APA convention in Boston, and later in print in American
Psychologist (2000). In this article, Beutler again addressed the question
of translating scientific evidence to clinical practice and did that in a way
that could be translated and applied to everyday decision making in select-
ing the best treatment option. The article finishes with a set of empirically
derived basic guidelines that reflect the decisions resulting on patient prog-
nosis, level of risk, and recommendations for use of various modalities and
formats of treatment, as well as guidelines for treatment enhancement and
optimization.
Larry’s quest for scientific discovery is so ingrained in him that you can
find him on both sides of some of the most recent discussions in our field. He was
a member of the APA Division 12 (Society of Clinical Psychology) task force
for empirically supported treatments and also a member of the Division 29
(Psychotherapy) task force on relationship ingredients. This means that he

was a prominent figure in the empirically supported treatment movement that
was initiated by the Society for Clinical Psychology within Division 12 of
APA, but later also prominent in the empirically supported relationships
movement with APA’s Division 29.
However, not entirely satisfied with the outcome, he promoted a new
movement for empirically based principles, trying to extract from research
studies principles of change that could guide clinicians in their daily work
with patients. This entailed a proposal to shift from focusing on manual-
defined treatments to identifying empirically established principles to guide
treatment. The structure and process of the movement’s task force are pre-
sented in a coauthored article (Castonguay & Beutler, 2006a) and a coedited
book (Castonguay & Beutler, 2006b).
It is fair to say that Larry’s views have always been informed by scien-
tific data and also infused with a sense of what others may be experiencing
clinically. This preoccupation is clear when, in his numerous works, he states
that the therapist should struggle to match the individual patient with the
most optimal treatment. But what about the patient who feels that the
treatment is not optimal and not producing results? That empathic perception
led Beutler to write a helpful book (Beutler, Bongar, & Shurkin, 2000),
originally titled Am I Crazy or Is It My Shrink? (reprinted as A Consumer’s Guide
to Psychotherapy: A Complete Guide to Choosing the Therapist and Treatment
That’s Right For You).
OTHER CONTRIBUTIONS
Larry Beutler can claim an impressive collection of acknowledgments

of his scientific achievements. For example, he served as president of APA
Division 29 and APA Division 12 (Clinical) and as president of the Society
for Psychotherapy Research (SPR). Among his citations and achievements
he can count the Distinguished Career Award from SPR, the Gold Medal
Award from the American Psychological Foundation, and a presidential
citation for achievement from APA. He has also been honored for his
contributions by the states of Arizona and California. As noted, the scholarly
publications that he has written or to which he has contributed number in
the hundreds.
Larry Beutler has made continuous and major contributions to the
renowned Journal of Consulting and Clinical Psychology. After serving on the
editorial board from 1975 to 1983, he was associate editor from 1984 to 1989
and editor from 1990 to 1995. As editor, he not only published scientifically
excellent research reports but also organized a number of special sections
that brought together the best thinking in the field at the time on such topics

as theoretical developments in the cognitive psychotherapies, single-case
research in psychotherapy, curative factors in dynamic psychotherapy, smoking
cessation, and the analysis of the process of change. Under his editorship,
JCCP reprinted historic papers by Cattell, Eysenk, Super, and Rogers.
One of us (Clarkin) was fortunate enough to work for the editorial group
under Beutler during the latter’s involvement with the journal and observed
his way of managing the difficult and often thankless task of editorship. The
acceptance of outstanding articles for publication takes judgment and leads
to joy and gratitude on the part of the authors. The rejection of articles can
tear at the fragile sense of competence and self-esteem in young researchers.
As editor, Beutler had to summarize the criticisms of the reviewers and deliver
the bad news to those who were to receive rejection letters. His rejection
letters were a beauty to behold. Like a good parent, effective mentor (caring
horse trainer?), Beutler had a way of praising the author for the merits of
the investigation and delivering the bad news with a strong ray of hope for
future efforts.
His editorial contributions were not limited to JCCP, however. He
served as editor, with Ken Howard, a longtime and dear friend deeply missed,
of the Journal of Clinical Psychology and again promoted numerous special
sections that became references in the field of psychotherapy research.
Larry Beutler is a powerful and influential force in psychology in the
United States, but his influence is not contained by U.S. boundaries. He has
traveled frequently and has developed long-term collaborations with groups
in several countries and regions around the world. One of us (Fernández-
Álvarez) witnessed the impact of these collaborations in the development
of psychotherapy research in South America. Since his first trip to South
America in 1992 to attend an international meeting organized by the Aiglé
Foundation in Buenos Aires, Beutler has visited frequently, giving seminars
that helped the development of the field in South America. Another of us
(Machado) witnessed a similar process in Europe, namely, in Portugal and
Spain, countries that Larry has visited over the years, having established close
ties with the University of Minho in Portugal and the University of Granada
in Spain.
In addition to these accomplishments, Beutler has always had an interest
in the training of psychotherapists and psychotherapy researchers. Needless
to say, he has written several publications on this topic, but mostly he has
influenced several generations of students. As a mentor, he has always had
a strong commitment to helping every student’s personal and professional
development. He has a long list of students not only in the United States but
around the world, several committed to academic careers and the field of
psychotherapy research.

CONCLUSION
The measure of an individual’s contribution to a field of study is multi-

faceted. If one judges the contribution from the number and extent of impact-
ful research contributions to the field, Larry Beutler can be viewed as a giant
in psychotherapy research. If the measure of contribution is the individual’s
role in the organizational and scholarly advance of the field of study, Larry
is a provocateur by virtue of the challenges he presented to the field, but
he is also a leader and a great team player. Finally, and most important, if
the measure of contribution is the modeling effect of the individual on the
next generation of researchers and practitioners in the field, Larry Beutler
is a folk hero.
Currently, he is most likely to be found either in one of the academic
campuses of Stanford or on his ranch in Northern California, where he lives
with his wife, Jamie Blitzer (whom he married in 2004). In Northern California
he seems to have the best of all worlds, given his academically stimulating
environment in psychology and the opportunity to return to his childhood love
of animals, working with horses and finding a sense of peace. When asked for
some words of wisdom, he quoted one of the principles of working with horses,
and he sees no reason not to use it as a metaphor for the delicate balance
between the many facets of psychotherapy that occupied his long and fruitful
academic career: “A horse doesn’t care about how much you know, until he
knows how much you care.”
REFERENCES
Beutler, L.E. (1979). Toward specific psychological therapies for specific conditions.
Journal of Consulting and Clinical Psychology, 47, 882–897.
Beutler, L. E. (1983). Eclectic psychotherapy: A systematic approach. New York, NY:
Pergamon.
Beutler, L. E. (1991). Have all won and must all have prizes? Revisiting Luborsky
et al.’s verdict. Journal of Consulting and Clinical Psychology, 59, 226–232.
doi:10.1037/0022-006X.59.2.226
Beutler, L. E. (2000). David and Goliath: When psychotherapy research meets
health care delivery systems. American Psychologist, 55, 997–1007. doi:10.1037/
0003-066X.55.9.997
Beutler, L. E., Bongar, B., & Shurkin, J. L. (2000). A consumer’s guide to psychotherapy:
A complete guide to choosing the therapist and treatment that’s right for you. New York,
NY: Oxford University Press. (Originally published in 1998 as Am I crazy or is it
my shrink?)

Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection: Toward targeted
therapeutic interventions. New York, NY: Brunner/Mazel.
Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Guidelines for the systematic treatment
of the depressed patient. New York, NY: Oxford University Press.
Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Meredith, K., & Merry,
W. (1991). Predictors of differential response to cognitive, experiential, and
self-directed psychotherapeutic procedures. Journal of Consulting and Clinical
Psychology, 59, 333–340. doi:10.1037/0022-006X.59.2.333
Beutler, L. E., Moleiro, C., & Talebi, H. (2002). How practitioners can systematically
use empirical evidence in treatment selection. Journal of Clinical Psychology, 58,
1199–1212. doi:10.1002/jclp.10106
Beutler, L. E., Patterson, K. M., Jacob, T., Shoham, V., Yost, E., & Rohrbaugh, M.
(1993). Matching treatment to alcoholism subtypes. Psychotherapy, 30, 463–472.
doi:10.1037/0033-3204.30.3.463
Castonguay, L. G., & Beutler, L. E. (2006a). Principles of therapeutic change: A task
force on participants, relationship, and techniques factors. Journal of Clinical
Psychology, 62, 631–638. doi:10.1002/jclp.20256
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006b). Principles of therapeutic change that
work: Integrating relationship, treatment, client, and therapist factors. New York,
NY: Oxford University Press.
Frances, A., Clarkin, J. F., & Perry, S. (1984). Differential therapeutics in psychiatry:
The art and science of treatment selection. New York, NY: Brunner/Mazel.

28
SIDNEY J. BLATT: RELATEDNESS,
SELF-DEFINITION,
AND MENTAL REPRESENTATION
JOHN S. AUERBACH, KENNETH N. LEVY, AND CARRIE E. SCHAFFER
Within the field of clinical psychology, contributors who are both psycho-
analysts and leading empirical researchers are increasingly rare. Yet one figure
who has made extensive contributions as an analytic clinician, as a researcher,
and as a theoretician is Sidney J. Blatt. In addition to being trained as a psycho-
analyst, he has conducted extensive research on personality development,
psychological assessment, psychopathology, and psychotherapeutic outcomes.
Along with his many students and colleagues, he has developed several widely
used measures, both self-report and projective, for assessing depressive style,
self- and object representations, and boundary disturbances in thought disorder.
In short, Sid has been a wide-ranging and productive scholar in a career of more
than 40 years’ duration, and throughout this career he has been committed
to the proposition that it is not only possible but also essential to investigate
psychoanalytically derived hypotheses through rigorous empirical science.
SUMMARY OF MAJOR CONTRIBUTIONS
Sidney Blatt is known for two fundamental ideas: his two-configurations

model, which delineates between anaclitic (or relational) and introjective
329
(or self-definitional) forms of depression (e.g., Blatt, 1974; Blatt & Shichman,
1983) and his cognitive morphology of personality development and psycho-
pathology (e.g., Blatt, 1991, 1995b). Regarding the two-configurations model,
Blatt early in his career began to differentiate between relational forms of
depression, which derive from interpersonal dependence and experiences
of loneliness and loss, and self-definitional forms, which involve experiences
of guilt, self-criticism, and failure. He has applied this distinction to psycho-
pathology in general, personality development, and psychotherapy research.
Regarding his cognitive morphology, Blatt proposed a psychoanalytically
informed cognitive developmental model of personality, according to which
psychological growth involves the maturation of underlying representational
structures of interpersonal or object relations. Initially, these representational
structures focus primarily on need gratification, and they progress toward
representations that integrate this early focus on needs with abstract concep-
tual properties involving complex psychological states and intersubjectivity
(e.g., Blatt, Auerbach, & Levy, 1997; Diamond, Kaslow, Coonerty, & Blatt,
1990). Blatt’s broad theoretical ideas serve as the foundation for his psycho-
therapy research, with its focus on how personality style and level of develop-
ment influence clinical outcome. In those studies, Blatt and his collaborators
demonstrated how anaclitic and introjective patients have very different
responses to psychotherapy, whether short-term or long-term, whether behav-
ioral or psychoanalytic, and how the personality of the patient may indeed
matter as much as or more than the type of the psychotherapy he or she
receives.
EARLY BEGINNINGS
The oldest of three children, Sidney Blatt was born on October 15, 1928,
to Harry and Fannie Blatt. Raised in modest circumstances, he grew up in a
Jewish family in South Philadelphia, where his father owned a sweets shop;
his family lived in the apartment upstairs. Sid recalls that every year he would
accompany his father to the cemetery where his grandmother was buried, and
there Sid would hold his father’s hand and attempt to console him as his
father wept over the grave. Sid also recalls that, at age 13, he accompanied
his mother on a painful 2-hour bus trip to New Jersey as she responded to an
urgent phone call informing her that her father had just suffered a heart
attack. He tried to comfort his mother during the trip while she, correctly
anticipating her father’s death, grieved his loss. Regarding these childhood
memories, Sid says that it is no surprise that he eventually was to become
interested in studying depressive experiences that focus on separation and loss.
He further recalls that, at age 9, he became disillusioned with his father for
330 AUERBACH, LEVY, AND SCHAFFER

failing to support him in what he describes as some minor but symbolically
important matter. Sid decided to run away from home. He defiantly packed
his bags and left the house, but within a few blocks he became aware that he
could not remember what his mother looked like; he ran home in a panic. Sid
says that this terrifying memory may be one of the roots of his lifelong interest
in the mental representation of the important people in one’s life.
Sid’s interest in psychoanalysis began in high school with his reading of
Freud’s “Introductory Lectures on Psycho-Analysis” (see Strachey, 1963). He
was fascinated by Freud’s descriptions of unconscious processes. Then, as a
psychology major at Penn State, Sid extended his earlier interest in psycho-
analysis to an emerging interest in projective testing. When taking a group
Rorschach in one of his classes, Sid was intrigued by how much his responses
revealed about himself.
Between his sophomore and junior years at Penn State he was intro-
duced, by one of his fraternity brothers, to Ethel Shames. He and Ethel married
on February 1, 1951, and were eventually to have three children, Susan, Judy,
and David. Sid says that without Ethel by his side, his professional accom-
plishments would have been impossible.
In 1950, Sid entered the graduate program in psychology at Penn State
and worked under William Snyder, a student of Carl Rogers. In 1952, he com-
pleted his master’s degree and received honors for his thesis, later published
in Archives of General Psychiatry (Blatt, 1959). In 1954, Sid entered the PhD
program in psychology at the University of Chicago and found the “U of C
an intellectual paradise,” where he maintained an ever-increasing list of
“must-read books and articles” (Auerbach, Levy, & Schaffer, 2005, p. 5). He
did his predoctoral internship in 1955 and 1956, under the supervision of Carl
Rogers, whom he still describes 40 years later, even after his analytic training,
as a profound influence on his psychotherapeutic approach. From Rogers, he
learned the crucial importance of empathy—of understanding how his patients
experienced the world and of framing his therapeutic interventions from the
patient’s standpoint. He also worked as a research assistant for Morris I. Stein,
who had been a student of Henry Murray’s at Harvard and who served as the
chair for Blatt’s dissertation (“An Experimental Study of the Problem Solving
Process”), completed in 1957 and retitled and published shortly thereafter
(Blatt & Stein, 1959). The other major influence on Blatt’s thought, however,
was not one of his teachers but David Rapaport (1951), whose ideas gave
Blatt a deeper theoretical understanding of the workings of the mind, a way
of linking motivation and cognition.
After a postdoctoral fellowship at the University of Illinois Medical
School and at Michael Reese Hospital’s Psychiatric and Psychosomatic
Institute, then headed by Roy Grinker Sr., Sid joined the Department of
Psychology at Yale University as an assistant professor in 1960. He was also
SIDNEY J. BLATT 331

accepted for analytic training at the Western New England Institute for
Psychoanalysis (WNEIP). At the WNEIP, Sid hoped to have a chance to
work directly with Rapaport, whose intellectual contributions Sid had come to
admire enormously. Rapaport died suddenly on December 14, 1960. Although
crestfallen about losing the opportunity to work with Rapaport, Blatt had already
established a relationship with Roy Schafer, his Yale faculty colleague. From
Schafer, who had worked extensively with Rapaport (see Rapaport, Gill, &
Schafer, 1945–1946), Blatt learned in greater depth the subtleties of Rapaport’s
thinking. In July 1963, he became chief of the Yale psychiatry department’s
Psychology Section, the position he holds to this day.
ACCOMPLISHMENTS
Two-Configurations Model
Although Sidney Blatt’s earliest interests were in psychological testing

and mental representation (e.g., Allison, Blatt, & Zimet, 1968), it was with
his two-configurations approach to psychopathology, depression in particu-
lar, that he came into his intellectual own. In 1972, Blatt completed his
psychoanalytic training, and his experiences with his two training cases led
him to formulate the anaclitic–introjective distinction (Blatt, 1974). Although
each of these patients suffered from depression, one proved to be highly
self-critical and guilt-ridden, with much suicidal ideation, and the other was
highly dependent, wanting nurturance and desperately seeking emotional
contact. From these experiences, Blatt proposed that some depressed patients,
whom he termed introjective because of their excessively harsh introjects, are
focused mainly on self-criticism, guilt, failure, and a need for achievement
and that others, whom he termed anaclitic because of their need to lean on
others for emotional support, are concerned mainly with loss, separation,
abandonment, and a need for emotional contact. Later, Blatt expanded this
classification to apply to other forms of psychopathology (Blatt & Shichman,
1983), as well as to personality development (Blatt & Blass, 1990). As he
expanded the scope of this model, he also became interested in attachment
theory and intersubjectivity theory, primarily as a result of the influence of
younger colleagues (see, e.g., Auerbach & Blatt, 2001; Diamond & Blatt,
1994; Levy, Blatt, & Shaver, 1998; Schaffer, 1993), and his terminology
shifted from anaclitic and introjective to the more inclusive distinction
between attachment or relatedness on the one hand and separateness or self-
definition on the other (e.g., Blatt & Blass 1990). Thus, this tension between
relatedness and self-definition has been central to Blatt’s understanding of
human life.

Blatt recognized that his theories needed grounding in empirical evi-
dence. He and his colleagues therefore developed the Depressive Experiences
Questionnaire (DEQ; Blatt, D’Afflitti, & Quinlan, 1976), a self-report scale
that assesses the two types of depression, anaclitic (or dependent) and intro-
jective (or self-critical). The measure has now been validated in numerous
studies (see Blatt, 2004), and an adolescent version of the measure has also
been constructed (Blatt, Schaffer, Bers, & Quinlan, 1992).
Representational Theory and the Cognitive Morphology
Although Blatt is perhaps best known for his work on the two-
configurations model, he has always developed his cognitive representational
understanding of personality and psychopathology in conjunction with his
understanding of relatedness and self-definition. In 1974, he delineated a
Piaget-influenced cognitive affective model of personality development.
He proposed (e.g., Blatt, Chevron, Quinlan, Schaffer, & Wein, 1988; Blatt,
Wein, Chevron, & Quinlan, 1979) that personality development proceeds
from a sensorimotor-enactive stage, in which a person’s object relations are
dominated by concerns with gratification and frustration, through a concrete
perceptual stage, in which object relations are based on what the other looks
like, an external iconic phase, in which object relations involve mainly what
others do, an internal iconic phase, in which object relations involve mainly
what others think and feel, and finally, a conceptual stage, in which all previous
levels are integrated into a complex, coherent understanding of significant
others. Blatt used this model in developing the Conceptual Level Scale for
rating open-ended descriptions of parents and other significant figures. Later,
he integrated ideas from the two-configurations model with concepts from his
representational model of cognitive development and from intersubjectivity
theory in constructing the Differentiation–Relatedness Scale (Diamond
et al., 1990; Diamond, Blatt, Stayner, & Kaslow, 1991), a measure that rates
significant-figure descriptions from a more relational perspective. The theo-
retical assumptions underlying these scales are that cognitive development and
the development of object relations occur in parallel and that the emergence
of psychopathology is closely linked to disturbances in the development
of object relations and cognitive organization (Behrends & Blatt, 1985). For
example, low levels of differentiation–relatedness are usually found in psychosis,
intermediate levels in borderline states, and higher levels in neurotic conditions
and normality. Gradually, therefore, Blatt articulated his cognitive morphology,
a comprehensive, integrated model of personality development, psycho-
pathology, and therapeutic change that connects psychological maturation to
the level of an individual’s representation of significant interpersonal relation-
ships (Blatt, 1991, 1995b; Blatt & Blass, 1990; Blatt & Shichman, 1983).
SIDNEY J. BLATT 333

Psychotherapy Research
In recent years, Blatt has applied these theoretical ideas to concrete

questions like what changes in treatment and how. Regarding his representa-
tional theories, Blatt and his colleagues found, in a sample of severely disturbed
adolescents and young adults in long-term psychoanalytically oriented inpatient
treatment, that changes in the structure and content of representations of
self and significant others, in variables like conceptual level, differentiation–
relatedness, and thematic content, were related to independent assessments
of clinical improvement (Blatt, Auerbach, & Aryan, 1998; Blatt, Stayner,
Auerbach, & Behrends, 1996). Specifically, they found that more positive
and better articulated representations of mother and therapist, along with the
expression of negative feelings about father, paralleled improvements in
global functioning. They also found that more differentiated representations
of the therapist are crucial for allowing patients to find and describe in others
their own positive qualities and then to reappropriate these psychological
strengths in a more integrated manner.
Blatt has also shown that relationally oriented and self-definitionally
oriented persons have differential responses to psychotherapy. In his reanalysis
of Wallerstein’s (1986) Menninger Psychotherapy Research Project (Blatt,
1992), Blatt found that self-critical patients responded better to psychoanalysis
and that dependent patients responded better to psychotherapy, with the
increased support provided by face-to-face interaction. Meanwhile, his study
(Blatt & Ford, 1994) of therapeutic change in long-term inpatient treatment
at the Austen Riggs Center in Stockbridge, Massachusetts, found that depen-
dent patients changed most with regard to interpersonal functioning, whereas
self-critical patients, who tend to be ideational, rather than affective, in their
orientation to the world, showed change primarily through improved cogni-
tive functioning and decreased thought disorder. These studies showed that
personality characteristics can crucially determine what kinds of therapeutic
interventions prove to be effective.
Stronger support for his model, however, has been a series of reanalyses
by Blatt and his colleagues (e.g., Blatt, Quinlan, Pilkonis, & Shea, 1995;
Shahar, Blatt, Zuroff, & Pilkonis, 2003; Zuroff & Blatt, 2006; Zuroff, Blatt,
Krupnick, & Sotsky, 2003) of the National Institute of Mental Health Treat-
ment of Depression Collaborative Research Program (TDCRP). Blatt and his
colleagues identified two factors in psychological functioning in the sample:
perfectionism (a proxy for self-criticism) and need for approval (a proxy for
dependence). They found that, regardless of the form of psychotherapy
used (i.e., cognitivebehavioral, interpersonal, medication, and placebo),
perfectionism had a negative effect on outcome in short-term treatment of
depression, presumably because patients with high standards were unlikely to

resolve their problems in just 15 or 20 sessions. These findings prompted Blatt
(1995a) to argue that introjective or self-critical patients need long-term
treatment to effect change. Thus, these research findings suggested not only
that personality differences are important in response to psychotherapy but
also that the short-term treatments that may be imposed on psychotherapy
patients by managed care might have significant countertherapeutic effects on
perfectionistic patients. In his reanalyses of the TDCRP, Blatt and colleagues
also found, as have many psychotherapy researchers before him, that a positive
therapeutic relationship, early in short-term treatment, predicted both symp-
tom reduction and enhanced adaptive capacity, above and beyond patient
characteristics and type of therapy. Thus, Blatt’s reanalyses of archival data
produced evidence that confirmed his psychoanalytically informed predic-
tions that therapeutic alliance and underlying personality dimensions, not
manualized treatments, are the chief determinants of therapeutic outcome
(Blatt & Zuroff, 2005), and this is one of his most important contributions.
INFLUENCES AND INFLUENCE
Blatt’s long-term colleagues, many of whom were students of David

Rapaport and therefore as much influences on Sid as influenced by him, have
included the members of the Rapaport–Klein Study Group, a small group that
has met annually at Austen Riggs since 1963 to pursue Rapaport’s and George
Klein’s efforts to extend psychoanalytic theory by putting it to empirical test.
In addition, Blatt’s approach to psychoanalysis was deeply influenced by Hans
Loewald, for many years the preeminent analytic theorist in New Haven, and
other important colleagues in New Haven have included Stephen Fleck, Jesse
Geller, Theodore Lidz, and Jerome Singer.
Sid Blatt has influenced the field of psychotherapy not only through
his ideas and his research but also through his relationships with 5 decades of
colleagues, both those who came before him, many of whom we have already
mentioned, and those who were his peers, undergraduates, graduate students,
psychiatry residents, psychology interns, and postdoctoral fellows. To trace lines
of influence from Blatt, perhaps the best known of his dissertation students is
Paul Wachtel, who has himself become a leading contributor to the psycho-
therapy field. Other examples of Blatt’s influence on colleagues can be found
in a Festschrift (Auerbach et al., 2005) that summarizes the fruits of his many
collaborations over the years. Particularly revealing of Blatt’s influence is that
more than 300 dissertations in the past 25 years have used measures that he
and his colleagues developed. However, his most generative contributions, in
our view, are two basic ideas: the two-configurations model and the cognitive
morphology. These two concepts have influenced not only his many academic
SIDNEY J. BLATT 335

collaborators but unnamed practicing clinicians who think differently about
psychotherapy and psychopathology because of them.
CONCLUSION
Sidney Blatt has integrated two main ideas into psychotherapy research:
(a) the role of differences in patient personality characteristics and (b) the
importance of changes in cognitive representational aspects of personality.
Perhaps his most important contribution to psychotherapy is to have shown
that anaclitic and introjective patients have differential responses to treat-
ment that may have more influence on therapeutic outcome than the specific
therapy or therapies to which they are assigned. Thus, the distinction between
relatedness and self-definition that Sid Blatt, inspired by psychoanalytic theory,
began exploring some 35 years ago has had relevance not only for psycho-
pathology, personality theory, and psychoanalysis, as Sid originally theorized,
but for short-term, nonpsychoanalytic approaches to therapy as well. In a field
that remains divided by theoretical approach and that lacks the unified body
of knowledge that characterizes physical sciences, it is no small accomplish-
ment to have ideas that are relevant across theoretical boundaries. But this
broad relevance is precisely the case in Sidney Blatt’s work, perhaps because
he has always worked to translate complex psychoanalytic ideas into concepts
useful to clinicians and researchers of all theoretical persuasions—in essence,
because he has lived with the tension of simultaneously asking deep questions
about what it means to be human and submitting his ideas to empirical test.
REFERENCES
Allison, J., Blatt, S. J., & Zimet, C. N. (1968). The interpretation of psychological tests.
New York, NY: Harper & Row.
Auerbach, J. S., & Blatt, S. J. (2001). Self-reflexivity, intersubjectivity, and therapeutic
change. Psychoanalytic Psychology, 18, 427–450. doi:10.1037/0736-9735.18.3.427
Auerbach, J. S., Levy, K. N., & Schaffer, C. E. (2005). Relatedness, self-definition, and
mental representation: Essays in honor of Sidney J. Blatt. London, England: Routledge.
Behrends, R. S., & Blatt, S. J. (1985). Internalization and psychological development
throughout the life cycle. Psychoanalytic Study of the Child, 40, 11–39.
Blatt, S. J. (1959). Recall and recognition vocabulary: Implications for intellectual
deterioration. Archives of General Psychiatry, 1, 473–476.
Blatt, S. J. (1974). Levels of object representation in anaclitic and introjective
depression. Psychoanalytic Study of the Child, 29, 107–157.
Blatt, S. J. (1991). A cognitive morphology of psychopathology. Journal of Nervous
and Mental Disease, 179, 449–458. doi:10.1097/00005053-199108000-00001

Blatt, S. J. (1992). The differential effect of psychotherapy and psychoanalysis on
anaclitic and introjective patients: The Menninger Psychotherapy Research
Project revisited. Journal of the American Psychoanalytic Association, 40, 691–724.
Blatt, S. J. (1995a). The destructiveness of perfectionism: Implications for the
treatment of depression. American Psychologist, 50, 1003–1020. doi:10.1037/
0003-066X.50.12.1003
Blatt, S. J. (1995b). Representational structures in psychopathology. In D. Cicchetti
& S. Toth (Eds.), Rochester symposium on developmental sychopathology: Vol. 6.
Emotion, cognition, and representation (pp. 1–33). Rochester, NY: University of
Rochester Press.
Blatt, S. J. (2004). Experiences of depression. Washington, DC: American Psychological
Blatt, S. J., Auerbach, J. S., & Levy, K. N. (1997). Mental representations in person-
ality development, psychopathology, and the therapeutic process. Review of
General Psychology, 1, 351–374. doi:10.1037/1089-2680.1.4.351
Blatt, S. J., Auerbach, J. S., & Aryan, M. (1998). Internalization, separation-
individuation, and the therapeutic process. In. R. F. Bornstein & J. M. Masling
(Eds.), Empirical studies of psychoanalytic theories: Vol. 8. Empirical studies of the ther-
apeutic hour (pp. 63–107). Washington, DC: American Psychological Association.
Blatt, S. J., & Blass, R. B. (1990). Attachment and separateness: A dialectic model
of the products and processes of psychological development. Psychoanalytic Study
of the Child, 45, 107–127.
Blatt, S. J., Chevron, E. S., Quinlan, D. M., Schaffer, C. E., & Wein, S. J. (1988).
The assessment of qualitative and structural dimensions of object representations
(rev. ed.). Unpublished research manual, Yale University, New Haven, CT.
Blatt, S. J., D’Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in
normal young adults. Journal of Abnormal Psychology, 85, 383–389. doi:10.1037/
0021-843X.85.4.383
Blatt, S. J., & Ford, R. (1994). Therapeutic change: An object relations perspective.
New York, NY: Plenum.
Blatt, S. J., Quinlan, D. M., Pilkonis, P. A., & Shea, T. (1995). Impact of perfectionism
and need for approval on the brief treatment of depression: The National
Institute of Mental Health Treatment of Depression Collaborative Research
Program revisited. Journal of Consulting and Clinical Psychology, 63, 125–132.
doi:10.1037/0022-006X.63.1.125
Blatt, S. J., Schaffer, C. E., Bers, S. A., & Quinlan, D. M. (1992). Psychometric
properties of the Adolescent Depressive Experiences Questionnaire. Journal of
Personality Assessment, 59, 82–98. doi:10.1207/s15327752jpa5901_8
Blatt, S. J., & Shichman, S. (1983). Two primary configurations of psychopathology.
Psychoanalysis and Contemporary Thought, 6, 187–254.
Blatt, S. J., Stayner, D., Auerbach, J. S., & Behrends, R. S. (1996). Change in object
and self representations in long-term, intensive, inpatient treatment of seriously
disturbed adolescents and young adults. Psychiatry, 59, 82–107.
SIDNEY J. BLATT 337

Blatt, S. J., & Stein, M. I. (1959). Efficiency in problem solving. Journal of Psychology,
48, 193–213.
Blatt, S. J., Wein, S. J., Chevron, E. S., & Quinlan, D. M. (1979). Parental represen-
tations and depression in normal young adults. Journal of Abnormal Psychology,
88, 388–397. doi:10.1037/0021-843X.88.4.388
Blatt, S. J., & Zuroff, D. C. (2005). Empirical evaluation of the assumptions in iden-
tifying evidence based treatments in mental health. Clinical Psychology Review,
25, 459–486. doi:10.1016/j.cpr.2005.03.001
Diamond, D., & Blatt, S. J. (1994). Internal working models and the representational
world in attachment and psychoanalytic theories. In M. B. Sperling & W. H.
Berman (Eds.), Attachment in adults: Clinical and developmental perspectives
(pp. 72–97). New York, NY: Guilford Press.
Diamond, D., Blatt, S. J., Stayner, D., & Kaslow, N. (1991). Self-other differentiation
of object representations. Unpublished research manual, Yale University, New
Haven, CT.
Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J. (1990). Change in separation-
individuation and intersubjectivity in long-term treatment. Psychoanalytic
Levy, K. N., Blatt, S. J., & Shaver, P. (1998). Attachment styles and parental repre-
sentations. Journal of Personality and Social Psychology, 74, 407–419. doi:10.1037/
0022-3514.74.2.407
Rapaport, D. (Trans. Ed.). (1951). Organization and pathology of thought. New York,
NY: Columbia University Press. doi:10.1037/10584-000
Rapaport, D., Gill, M. M., & Schafer, R. (1945–1946). Diagnostic psychological testing
(Vols. I and II), Chicago, IL: Year Book Publishers.
Schaffer, C. E. (1993). The role of attachment in the experience and regulation of affect.
Unpublished doctoral dissertation, Yale University, New Haven, CT.
Shahar, G., Blatt, S. J., Zuroff, D. C., & Pilkonis, P. A. (2003). Role of perfection-
ism and personality disorder features in response to brief treatment for depres-
sion. Journal of Consulting and Clinical Psychology, 71, 629–633. doi:10.1037/
0022-006X.71.3.629
Strachey, J. (Ed.). (1963). The standard edition of the complete psychological works of
Sigmund Freud: Vols. 15 & 16. Introductory lectures on psycho-analysis. London,
England: Hogarth Press. (Original work published 1916–1917.)
Wallerstein, R. S. (1986). Forty-two lives in treatment: A study of psychoanalysis and
psychotherapy. New York, NY: Guilford Press.
Zuroff, D. C., & Blatt, S. J. (2006). The therapeutic relationship in the brief treatment
of depression: Contributions to clinical improvement and enhanced adaptive
capacities. Journal of Consulting and Clinical Psychology, 74, 130–140. doi:10.1037/
0022-006X.74.1.130
Zuroff, D. C., Blatt, S. J., Krupnick, J. L., & Sotsky, S. M. (2003). Enhanced adaptive
capacities after brief treatment for depression. Psychotherapy Research, 13, 99–115.
doi:10.1093/ptr/kpg012

29
WILLIAM E. PIPER: NEGOTIATING THE
COMPLEXITIES OF PSYCHOTHERAPY
JOHN S. OGRODNICZUK
Successfully negotiating the complexities of the psychotherapeutic

process requires a lifetime of unwavering commitment, ingenuity, skill, and
leadership, which only a select few have demonstrated. One such researcher
who exemplifies the commitment that is necessary to succeed in this area of
research is Dr. William (Bill) Piper. With persistent dedication and a tena-
cious work ethic, Bill Piper has built a career out of answering complicated
clinical questions about what works for whom, and why. This chapter briefly
describes Bill’s personal and professional journey to becoming a distinguished
psychotherapy researcher.
MAJOR CONTRIBUTIONS
Much of Bill Piper’s work has been progressive in nature, involving serial
investigations that built upon each other in a systematic way. Thus, it is diffi-
cult and inappropriate to isolate particular studies as Piper’s major contribu-
tions. Instead, it is more apt to highlight the major themes of Piper’s research.
Certainly, the most prominent theme of Piper’s research program concerns
his focus on psychodynamically oriented psychotherapies. Piper found the
339
complexity of psychodynamic theories of normal and abnormal behavior to be
attractive. Their emphasis on unconscious processes was intriguing and fit with
his personal experiences and proclivity to think about underlying reasons for
these experiences. Although Piper was not among the first to study psycho-
dynamic psychotherapy, he was one of the early figures who consistently
applied rigorous methodological practices to the scientific study of psycho-
dynamic therapy.
William Piper’s career began at a time when a shift was occurring in the
field—a shift away from psychoanalytically based, long-term therapies to more
structured and short-term therapies. Although it would have been logical for
Piper to adjust his research program to this shift to survive as an academic, he
did not relent (commitment is, indeed, one of Bill’s endearing traits). His per-
sonal conviction that psychodynamic theory and therapy were appropriate and
necessary for understanding and working with the richness and complexities of
human mental development and psychopathology allowed him to stay the
course he had set for his research. Furthermore, Piper saw opportunity. With
the increasing emphasis on short-term and time-limited forms of therapy, Piper
was intrigued by the opportunity to study psychodynamic forms of therapy that
attempted to adopt such parameters. He went on to develop one of the most
comprehensive research programs on short-term, time-limited dynamic
psychotherapy in the field. Now, with the pendulum swinging back to the
middle, there is an increasing appreciation and renewed interest in psycho-
dynamic psychotherapy (Gabbard, Gunderson, & Fonagy, 2002). Piper’s work
in this area stands out as exemplary and is often referred to as a source for empir-
ical support of psychodynamic therapy.
Another theme that runs through much of Piper’s research, which has had
a significant impact on the field, concerns his focus on group psychotherapy.
The complexity of group dynamics and phenomena was intriguing and repre-
sented a challenge for Piper in terms of understanding how social processes can
contribute to both the development and amelioration of mental illness. Group
therapy research is also complex and not easy to conduct. Few have attempted
it in a consistent fashion. From his early days as a graduate student, Piper has
had an interest in groups. He was intrigued by the potentially powerful and
unique change agents in groups. His work has examined sensitivity training
groups for hospital corpsmen (Piper, 1972), long-term groups with mixed
patient samples (Piper, Debbane, & Garant, 1977), comprehensive group-
oriented partial hospitalization for patients with comorbid mood and personal-
ity disorders (Piper, Rosie, Azim, & Joyce, 1993), and short-term groups for
people who have not adapted well to death losses (Piper, McCallum, Joyce,
Rosie, & Ogrodniczuk, 2001), the latter of which is most dear to Piper’s heart.
Piper’s commitment to group therapy research has been praised as an
example of how to approach work in this area. For example, Burlingame,
340 JOHN S. OGRODNICZUK

Fuhriman, and Johnson (2004) commented that “Piper and his colleagues on
the Vancouver/Edmonton team have pursued one of the most progressive and
comprehensive programs of group research” (p. 654). Given the continued
growth of group therapy as a major treatment modality for people with psychi-
atric (e.g., major depression) and nonpsychiatric (e.g., breast cancer) difficul-
ties, and the increased use of time-limited group treatments by behavioral
health maintenance organizations (Taylor et al., 2001), Piper’s work is sure to
have a lasting impact on the field.
A third theme that runs through Piper’s research is the concept of match-
ing patients and treatments. To provide optimal treatment and maximize use
of health care resources, therapists have argued for a more sensitive and clini-
cally driven approach that matches patients to levels of care and treatment
modalities, thus providing a range of options tailored to the qualities of individ-
ual patients. The patient–treatment matching paradigm has considerable
potential for creating productive dialectic between theory, practice, and
research, and it should ultimately result in enhanced and efficient care. Yet,
despite its potential, research on patient–treatment matching in psychother-
apy is still in its infancy, and its full promise has not been realized. Few
researchers have attempted to systematically engage in this area of research,
likely because of the significant investment of resources and time that it requires.
Piper is among those who recognized the potential of patient–treatment match-
ing and dedicated much of his career to using this paradigm in his research. His
research in this area was an evolution. He started by attempting to identify
important patient characteristics that influenced whether patients remained,
worked, and benefited in psychotherapy. From there, he began to explore
whether these different patient characteristics had differential impacts depend-
ing on the type of therapy that is provided. His patient–treatment matching
studies involving individual and group forms of psychodynamic psychotherapy
stand as some of the better examples of this type of research to date.
A recurring theme in Bill Piper’s research is his attention to issues of ther-
apy process. Piper continually challenged himself to go beyond the basic issue
of whether a treatment worked and tackle the more complicated issue of how
a treatment worked. Although knowing which treatments are effective is
clearly important, Piper believed that clinicians would not be satisfied with this
information only. Instead, they wanted and needed to know more about what
to do during therapy in order to provide the best possible treatment to their
patients. Thus, process analysis became an integral part of all of Piper’s studies.
Rather than looking at certain variables in isolation, Piper’s research often inte-
grated treatment variables, process variables, and patient variables in the same
studies in order to examine more complex hypotheses about the mechanisms
of action that contribute to benefit in psychotherapy. Change processes associ-
ated with psychodynamic theory and group therapy are particularly complex.
WILLIAM E. PIPER 341

Piper was stimulated by the challenge of trying to elucidate these processes. The
field is developing a greater appreciation of the importance of understanding
psychotherapy change mechanisms (an example is the focus on “empirically
supported relationships”). Thus, Piper’s work in this area has served as a useful
example of how to tackle such issues.
The final theme that characterizes Piper’s work concerns the defini-
tion and measurement of important clinical constructs. Psychotherapy chiefly
involves changing internal processes so that a patient can function more adap-
tively. These internal processes are not directly observable and are often
described in complex, clinical terms. This makes psychotherapy research diffi-
cult. Clear operational definitions and reliable methods to assess constructs are
required. Piper’s efforts to define, observe, and measure various clinical con-
structs related to patient personality (e.g., quality of object relations), therapist
technique (e.g., transference interpretations), and group processes (e.g., group
cohesion) have helped to open doors for other researchers to study complex
clinical phenomena.
EARLY BEGINNINGS
Bill Piper is the oldest of three boys from a middle-class family from Ohio.
His father was a city fireman with a 10th-grade education who did not attribute
much value to academics. His mother was a housewife until his parents
divorced when he was 14 years old. She then went to work as a grocery store
clerk in order to support the family. Bill did well academically and was also
active in a number of sports, his favorites being basketball, tennis, and track.
He was also active in church, where he met his future wife, Martha. After grad-
uating from high school, Bill won a scholarship to attend a small liberal arts col-
lege in Wooster, Ohio. He initially chose to major in chemistry, at which he
excelled. However, after having taken an introductory psychology course in the
second semester of his 1st year, he decided that he found people more interest-
ing than molecules and declared psychology as his major. During his under-
graduate work, Bill completed an honors thesis that included a study of
feedback mechanisms in small groups. Bill contends that he became curious
about groups because he was shy. He recognized that he found group situations
to be intimidating, and he challenged himself to master and overcome his fears
by understanding group phenomena. After completing his undergraduate
degree, Bill applied to graduate school in clinical psychology and was accepted
at the University of Connecticut with a U.S. Public Health scholarship.
He was a graduate student in clinical psychology in the late 1960s, a time
when sensitivity training was very popular. Sensitivity training groups (or
T-groups, as they were called) were regarded as a relatively easy way to learn

about interpersonal relations and processes in general and to gain insight about
oneself in social situations in particular. Piper was keenly interested in having
a T-group experience and did so. However, his interest in what he could learn
about himself in T-groups was matched by a sense of danger. His graduate pro-
gram was part of the more conservative East Coast culture of the United States,
but he and his fellow students had heard about the uninhibited and unpre-
dictable groups of the West Coast. Rather than discourage them, however, it
all seemed to increase their curiosity about the varied effects of T-groups and
the apparent double-edged sword of psychotherapy.
Training in group therapy was not a strong part of his graduate program’s
curriculum. Yet, there were plenty of groups and opportunities to join these dif-
ferent groups in the mental health system associated with his university.
Among the opportunities that Piper took was an elective course on group ther-
apy. Standing behind a one-way mirror with a small group of other graduate stu-
dents, he first witnessed a therapy group in action. It was enough to capture his
interest. He was struck by the potential of powerful and unique change agents
in groups. Then he was called on to join a larger group.
In February 1968, he received his draft notice from the U.S. Army. He
was able to negotiate an 11-month delay to finish his coursework and exams in
Connecticut in exchange for serving for 3 years as a navy psychologist. In
January 1969, he began the first of his 3 years in the U.S. Navy as a psychology
intern at Bethesda Naval Hospital in Maryland. There he found plenty of
groups: T-groups for the interns, therapy groups on the inpatient wards, and
therapy groups in the outpatient services. Over the course of the year, Piper par-
ticipated in a sensitivity group and was able to serve as a beginner cotherapist
for two therapy groups. At the same time, he was in need of a dissertation topic
and project. Following the dictum that “necessity is the mother of invention,”
he chose to seize an opportunity at the Naval Hospital, which was also a train-
ing center for a number of health service specialists. For his project, he studied
the effects of sensitivity training groups on hospital corpsmen. Although the
findings of his study did not provide much evidence for the effectiveness of sen-
sitivity training groups in increasing interpersonal skills, the project proceeded
smoothly and convinced him that randomized controlled trials involving
groups could actually be conducted. Little did he know that such trials would
eventually become a central component of his research activities. After
Bethesda, he worked for the next 2 years in a psychiatric outpatient clinic at
Marine Corps Base Quantico, Virginia, and there his involvement in group
therapy lay somewhat dormant. In 1973, he left the Navy and joined the
Department of Psychology at McGill University, where his involvement in
group therapy was soon to revive.
Piper left the United States for Canada because there was an opening
in the middle of the academic year (January 1973) that coincided with his

departure from the U.S. Navy. He also knew that McGill had an excellent
academic reputation and that Montreal was an attractive city with a unique
European–North American culture. A few months after arriving in Montreal,
he learned that a psychiatrist, Elie Debbane, at the Allan Memorial Institute
was interested in creating a group psychotherapy unit that would promote
training, research, and practice. Along with another psychiatrist, Jacques
Garant, they forged a union that developed into a productive work group and
set of friendships. Piper’s early career was launched and continued with a
remarkable trajectory.
ACCOMPLISHMENTS
Between 1977 and 2008, Bill Piper completed a series of eight large-scale,
randomized clinical trials of psychotherapy. The studies’ objectives, design, and
methodology shared a number of common features. For example, each investi-
gated the efficacy of one or more forms of dynamically oriented psychotherapy,
most of which were short-term treatments. Also, in addition to including a large
battery of outcome assessments, his studies always monitored one or more
process variables during therapy, for example, therapeutic alliance and thera-
pist technique. Finally, all involved the assessment of patient characteristics to
help determine appropriate patient–treatment matches.
Each of these trials was significant in its own right, but a few stand out as
particularly meaningful to Piper and, likely, the field in general. The first of
these was conducted when Piper was at McGill in Montreal (Piper, Debbane,
Bienvenu, & Garant, 1984). The trial compared four forms of psychoanalyti-
cally oriented psychotherapy: individual or group therapy that lasted either
6 or 24 months. What emerged as important from this trial was the particular
form of therapy received, not the general type of therapy or the general dura-
tion of therapy. The results favored long-term group therapy and short-term
individual therapy. This stands as a landmark study because it remains one of
the few factorial designs in comparative therapy research.
A second significant trial occurred when Piper moved to the University
of Alberta in Edmonton. This study compared two different forms of dynami-
cally oriented, short-term individual therapy (Piper, Azim, McCallum, & Joyce,
1990). This was one of the first studies to use a patient–treatment matching par-
adigm. Specifically, the trial was designed to test the question of whether QOR
(quality of object relations; see Azim, Piper, Segal, Nixon, & Duncan, 1991;
Blatt, Wiseman, Prince-Gibson, & Gatt, 1991) had a differential effect on the
outcome of two very different types of therapy. The hypothesis was that
higher QOR patients were better suited for interpretive therapy and lower

QOR patients were better suited for supportive therapy. The findings sup-
ported this hypothesis. This study is among the better examples of this type of
research to date.
Another significant trial that Piper conducted in Edmonton examined
the efficacy of group-oriented partial hospitalization for patients with debili-
tating comorbid mood and personality disorders (Piper, Rosie, Azim, & Joyce,
1993). This type of intensive outpatient service held great promise. These
patients typically failed in usual once-a-week outpatient therapy and often
ended up in inpatient wards. Yet, inpatient treatment was not regarded as an
appropriate level of care for such patients. A treatment that could provide
an intermediate level of care was needed. The trial demonstrated that short-
term, time-limited partial hospitalization had a powerful, lasting impact on
patients, who improved on several aspects of functioning. This study remains
one of the very few randomized trials of partial hospitalization.
Most recently, since his move to Vancouver and the University of British
Columbia (UBC), Piper has led a large, multisite study. This trial was the lat-
est in a series of studies that investigated different forms of group therapy for
patients suffering from complicated grief and was designed to examine whether
the composition of therapy groups had an effect on the outcome of treatment
(Piper, Ogrodniczuk, Joyce, Weideman, & Rosie, 2007). The expectation was
that patients who were in a group with similar others and provided a form of
therapy that fit with their personality would do better than patients who were
in a group with a mixed variety of patients, regardless of whether the form of
therapy they were provided matched their personality. The findings, although
not completely supportive of this hypothesis, did find that composition matters.
In particular, the study found that the more high-QOR patients that are in a
group, the better everyone in the group did, regardless of each individual mem-
ber’s level of QOR or the form of therapy provided. This study is important
because it is one of the very few, if not only, clinical studies of composition
effects in group therapy. Currently, Piper is engaged in a study that is attempt-
ing to identify variables that mediate the effect of group composition.
Finally, no description of Piper’s accomplishments is complete with-
out mention of his process work. A series of studies on the effect of transfer-
ence interpretations best exemplifies Piper’s efforts to understand how the
processes of therapy impact patient outcomes (Ogrodniczuk & Piper, 2004).
Transference interpretations are an important feature of psychodynamic psy-
chotherapies. Despite their importance, the literature provides little guidance
regarding the use of these powerful interventions in the treatment of different
types of patients. Piper’s research on the dosage and correctness of transference
interpretations (and how these differ as a function of patient personality),
however, has contributed to our knowledge of the appropriate use of transfer-

ence interpretations. His findings argue for technical flexibility in the use of
transference interpretations, with the particular needs of patients as the pri-
mary determinant.
Much of Piper’s work can be found in several books that he has co-
authored (e.g., Piper, Joyce, McCallum, Azim, & Ogrodniczuk, 2002), several
of which in themselves represent significant contributions to the field. These
publications offer a glimpse into the way Piper thought about the various issues
at hand and his rationale for conducting his studies, how he designed his trials,
the findings from the trials and their implication for practice and research, and
clinical vignettes that give life to his work. Piper regards his books as a neces-
sary final step that follows a series of trials—a mechanism that allows him to
pull together his work in a way that appeals to both clinicians and researchers.
In fact, he perceives this as his responsibility as a clinical scientist.
OTHER CONTRIBUTIONS
Bill Piper has been a strident advocate of psychotherapy research in his

various administrative capacities. For example, as a member of the Randomized
Controlled Trials Committee for the Canadian Institutes of Health Research,
he helped bring greater awareness to the national health system of the value of
clinical trials in psychotherapy. Similarly, as the president of the Canadian
Group Psychotherapy Association, Piper was a strong voice for promoting
research in venues that were traditionally resistant to research. Even locally,
Piper has had a significant influence on the direction that mental health
research should take and the role of psychotherapy research. His efforts helped
in the creation of the UBC Institute of Mental Health Research, a $20 million
endeavour (the largest of its kind in Canada), which has identified psycho-
therapy research as one its three pillars. Of course, as a past president of the
Society for Psychotherapy Research, Piper was able to provide leadership and
direction to a large, international coalition of psychotherapy researchers.
INFLUENCES
It is possible that all of William Piper’s accomplishments in our field may

not have happened, were it not for a few key people in Piper’s early academic
career. Piper attests that Mike Wogan was probably the most influential person
with regard to steering him toward psychotherapy research. Mike was always
receptive to Piper’s ideas and conveyed excitement as Piper took on new chal-
lenges. Piper attributes his interest in groups to Herb Getter. Both Mike and
Herb were advisors on Piper’s master’s thesis committee. Carl Wagner was also

dear to Piper for being so helpful in facilitating his PhD work, which had to be
completed early because of his military service commitments. Finally, Elie
Debbane provided Piper with the support, encouragement, and camaraderie to
launch his career as an independent academic at McGill.
Piper received caring and supportive mentorship during his academic
training, which he, in turn, provided to his trainees. During his tenure at
McGill University, Piper supervised a good number of clinical psychology grad-
uates. Most of these graduates went on to become full-time clinicians. Mary
McCallum, who went on to build a successful research career instead, stands
out as an exception. Once Piper left McGill and went to the University of
Alberta and then to UBC, his academic setting was in psychiatry, not psychol-
ogy. He no longer had an opportunity to participate as a primary supervisor for
trainees in the same way that had he enjoyed it at McGill. Nevertheless, while
at the University of Alberta, Piper was able to take on two research trainees via
a unique partnership between the Faculty of Medicine and Faculty of Graduate
Studies. These trainees were Anthony Joyce and John Ogrodniczuk. To this
day, he maintains a strong connection with them, and together they form a
highly productive research team.
Throughout his career, Piper has enjoyed close, fruitful, and collaborative
relationships with a number of clinicians, who were keen to contribute in what-
ever way they could. These people include Hassan Azim, Elie Debbane, John
Rosie, John O’Kelly, and Rene Weideman. Piper has remarked on numerous
occasions, “My accomplishments are theirs as well.” He contends that these and
other clinicians played crucial roles in the development of his research program
because they were willing to evaluate the therapies that they practiced. They
reinforced his interest in the psychodynamic orientation and introduced him
to systems theory and to different ways to understand group phenomena. Piper’s
belief in the necessity of working with a team of people to accomplish impor-
tant objectives in life is evident in the strong bonds had has developed and
maintained with his colleagues over the years.
CONCLUSION
When one reads criticisms of the psychotherapy research literature, most

often they focus on the failure to examine commonly used clinical treatment
modalities, the failure to use experienced community-based clinicians, and the
neglect of relationship and patient variables that influence the success of
the therapeutic enterprise. Piper’s research, however, has always addressed
these issues and thereby has maximized the clinical relevance of his work. His
clinical trials often focus on commonly used clinical treatments (e.g., individ-
ual and group therapy) and his process work has centered on clinical constructs

widely viewed as central to dynamicallyoriented psychotherapy (e.g., transfer-
ence interpretations), group therapy (e.g., cohesion), and all therapies (e.g., the
alliance). In terms of important patient characteristics, Piper saw the impor-
tance of operationalizing the clinical notion of quality of object relations and
has examined this variable in relation to both the process and outcome of
psychotherapy. Many have recognized the value of and called for patient–
treatment matching studies over the years, but Piper has been one of the few
who have attempted such research. His work in this area has been second to
none and stands as an example for others to follow.
The implications of Piper’s work on the theory, practice, and research are
plentiful. From a theoretical perspective, Piper’s work compels us to think about
how a person’s internal representations of important people in his or her life
and the wishes and emotions attached to these representations can be activated
and modified within the context of a helping relationship to improve that per-
son’s life. With regard to practical implications, Piper’s work demonstrates the
importance of proper patient selection, matching patients and treatments, and
monitoring one’s technique during the course of treatment. Finally, from a
research perspective, Piper’s work shows us how we can move beyond the
important but rather rudimentary issue of whether a treatment works, toward
developing a better understanding of what kinds of treatment work with
whom and how they work. Piper’s theoretical innovation, dedication to help-
ing others, and commitment to science are sure to stimulate and engage others
to apply the highest degree of rigor for advancing the psychotherapy field.
REFERENCES
Azim, H. F. A., Piper, W. E., Segal, P. M., Nixon, G. W. H., & Duncan, S. (1991). The
quality of object relations scale. Bulletin of the Menninger Clinic, 55, 323–343.
Blatt, S. J., Wiseman, H., Prince-Gibson, E., & Gatt, C. (1991). Object representa-
tions and change in clinical functioning. Psychotherapy, 28, 273–283.
Burlingame, G. M., Fuhriman, A. J., & Johnson, J. (2004). Process and outcome in
group counseling and psychotherapy. In J. L. DeLucia-Waack, D. A. Gerrity,
C. R. Kalodner, & M. T. Riva (Eds.), Handbook of group counseling and psycho-
therapy (pp. 49–61). Thousand Oaks, CA: Sage.
Gabbard, G. O., Gunderson, J. G., & Fonagy, P. (2002). The place of psychoanalytic
treatments within psychiatry. Archives of General Psychiatry, 59, 505–510. doi:10.
1001/archpsyc.59.6.505
Ogrodniczuk, J. S., & Piper, W. E. (2004). The evidence: Transference interpretations
and patient outcomes. A comparison of “types” of patients. In D. Charman (Ed.),
Core processes in brief psychodynamic psychotherapy (pp. 165–184). Mahwah, NJ:
Erlbaum.

Piper, W. E. (1972). Evaluation of the effects of sensitivity training and the effects of vary-
ing group composition according to interpersonal trust. PhD dissertation, University
of Connecticut.
Piper, W. E., Azim, H. F. A., McCallum, M., & Joyce, A. S. (1990). Patient suitabil-
ity and outcome in short term individual psychotherapy. Journal of Consulting
Piper, W. E., Debbane, E. G., Bienvenu, J. P., & Garant, J. (1984). A comparative
study of four forms of psychotherapy. Journal of Consulting and Clinical
Psychology, 52, 268–279. doi:10.1037/0022-006X.52.2.268
Piper, W. E., Debbane, E. G., & Garant, J. (1977). An outcome study of group ther-
apy. Archives of General Psychiatry, 34, 1027–1032.
Piper, W. E., Joyce, A. S., McCallum, M., Azim, H. F., & Ogrodniczuk, J. S. (2002).
Interpretive and supportive psychotherapies: Matching therapy and patient personality.
Washington, DC: American Psychological Association. doi:10.1037/10445-000
Piper, W. E., McCallum, M., Joyce, A. S., Rosie, J. S., & Ogrodniczuk, J. S. (2001).
Patient personality and time-limited group psychotherapy for complicated grief.
International Journal of Group Psychotherapy, 51, 525–552.
Piper, W. E., Ogrodniczuk, J. S., Joyce, A. S., Weideman, R., & Rosie, J. S. (2007).
Group composition and group therapy for complicated grief. Journal of Consulting
Piper, W. E., Rosie, J. S., Azim, H. F. A., & Joyce, A. S. (1993). A randomized trial of
psychiatric day treatment. Hospital & Community Psychiatry, 44, 757–763.
Piper, W. E., Rosie, J. S., Azim, H. F. A., & Joyce, A. S. (1993). A randomized trial of
psychiatric day treatment. Hospital and Community Psychiatry, 44, 757–763.
Taylor, N. T., Burlingame, G. M., Fuhriman, A. J., Kristensen, K. B., Johansen, J., &
Dahl, D. (2001). A survey of mental health care provider and managed care
organization attitudes toward, familiarity with, and use of group interventions.
International Journal of Group Psychotherapy, 51, 243–263. doi:10.1521/ijgp.51.2.
243.49848

V
CONCLUSION
30
FUTURE DIRECTIONS: EMERGING
OPPORTUNITIES AND CHALLENGES
IN PSYCHOTHERAPY RESEARCH
LYNNE ANGUS, JEFFREY A. HAYES, TIMOTHY ANDERSON,
NICHOLAS LADANY, LOUIS G. CASTONGUAY,
AND J. CHRISTOPHER MURAN
With the publication of this volume, it is our hope that psychotherapy

researchers and practitioners will not only enjoy the stories that enrich our
shared past but will also have an opportunity to reflect on the emerging research
and practice trends that are likely to shape the fields of clinical and counseling
psychology, psychiatry, and social work in the years to come. Accordingly, in
this final chapter we identify core research themes for the identification of key
research issues that are likely to shape the future of psychotherapy research,
training, and practice.
ASSESSING PSYCHOTHERAPY OUTCOMES—

FROM RANDOMIZED CLINICAL TRIALS
TO PRACTITIONER–RESEARCHER NETWORKS
No doubt influenced by Eysenck’s (1952) challenging yet flawed review

of psychotherapy effectiveness, a number of pioneers of the Society for Psycho-
therapy Research (SPR), such as Rogers, Luborsky, and Strupp, developed
research programs aimed at measuring the outcome of insight-oriented treat-
ments (the main target of Eysenck’s review). Other researchers, such as Bergin,
353
Garfield, Howard, and Orlinsky, undertook the important task of collating,
critically evaluating, and disseminating outcome research findings through
the publication of landmark texts such as the Handbook of Psychotherapy and
Behavior Change (Bergin & Garfield, 1978).
Irene Elkin’s innovative effort to refine randomized controlled research
designs for application in multisite collaboration psychotherapy research
trials, the Treatment of Depression Collaborative Research Program, set the
stage for the development of brief therapy approaches designed to address
specific clinical disorders such as depression and anxiety. In addition to
Elkin, numerous researchers featured in this book have conducted random-
ized clinical trial (RCT)-based therapy outcome studies that have con-
tributed to the establishment of empirical support for psychodynamic
(Blatt, Luborsky, Piper, Shapiro, Strupp), interpersonal (Strupp), client-
centered/emotion-focused (Greenberg), gestalt/emotion-focused (Beutler),
and cognitive behavioral (Beck, Beutler, Goldfried, Grawe, Shapiro) treat-
ments for depression.
The number and variety of comparative treatment trials that have been
completed over the past 30 years clearly attest to the impact that RCT
designs and the evaluation of treatment outcomes have had on the field of
psychotherapy research and practice as a whole. However, the equivalency
of positive outcome findings achieved across different therapy approaches
for the treatment of depression has led a number of researchers (Strupp,
Goldfried, Elliott, Howard, Piper) to question whether future research efforts
and funding should be focused on RCT designs that test differential treat-
ment approaches for specific clinical disorders. Several researchers have
encouraged the field to go one step beyond the question of whether one ther-
apy is superior to another and have emphasized the importance of conduct-
ing studies to identify what forms of treatment might be more effective for
particular types of clients or clinical problems (Beulter, Blatt, Grawe, Elkin,
Jones, Kiesler, Piper, Stiles).
Influential contributors such as Frank, Bordin, Luborsky, Strupp, and
Orlinsky have long advocated taking a new direction in psychotherapy
research and funding that would entail the identification and empirical vali-
dation of key mechanisms of change—across therapy approaches—that are
causally linked to efficacious treatment outcomes. Frank and Goldfried, along
with Castonguay and Beutler (2006), have also suggested that if we are to
understand how therapists can achieve more effective clinical outcomes with
their patients, future research efforts should focus on the identification and
empirical evaluation of a shared corpus of key principles of change that are
evidenced in a diverse range of evidence-based practices. Understanding
specifically how, when, and where key principles of change are most effec-
354 ANGUS ET AL.

tively used for productive treatment outcomes, across differing therapy
approaches, will be an important future direction for this challenging research
initiative.
Additionally, there is mounting criticism from key contributors to the
psychotherapy research and practice field that the patient selection criteria used
in RCTs is unduly restrictive and not representative of the complex symptom
profiles that patients often present with in community-based settings. They also
argue that the use of approach-specific therapist treatment manuals, mandatory
for adherence ratings in RCTs, unduly limits the ability of therapists to respon-
sively and flexibly meet the complex needs of patients who are often seen in
community-based clinical practice. This is a particularly important issue for psy-
chotherapy practitioners who may be required to use evidence-based therapy
approaches with their patients. Taken together, critics have questioned the util-
ity, generalizability, and validity of RCT-based research findings for clinicians
who practice in real-world settings and have challenged major research fund-
ing agencies and clinical researchers to draw on sample practitioners engaged
in community practices for future research trials. Indeed, a vitally important
future research question remains to be answered in this regard: Can RCT exper-
imental designs be adapted for implementation in community-based samples
and still address key methodological issues such as random assignment to
treatment, client diagnostic heterogeneity, and consistent adherence to
specific treatment manuals? Alternatively, do psychotherapy researchers
need to develop a new gold standard for the evaluation of effective clinical
practices that not only accommodates but capitalizes on the heterogeneity of
practice approaches and client diagnostic issues that abound in real-world clin-
ical settings? Resolving these important key methodological and practice-based
research issues will certainly shape the direction of psychotherapy research in
the years to come.
In response to these criticisms and in light of influential contribu-
tions of Howard, Orlinsky, and Bergin, a new generation of psychotherapy
researchers (e.g., Grawe, Lambert, Stiles, Elliott) have contributed to the
development of session level patient outcome measures for application
by practitioners in community-based settings (see Barkham et al., 2008).
The collection of large samples and statistical advances in linear growth
modeling has also allowed researchers to explore methods that can posi-
tively influence clinical decision making through feedback to therapists.
For instance, Lambert and colleagues (2001) recently established that
therapists in real-world practice settings and training centers are able to
achieve more effective treatment outcomes when they are given post-
session evaluations of their patient’s symptom status and level of distress.
The provision of patient feedback appears to significantly enhance treatment
FUTURE DIRECTIONS 355

outcomes by reducing early dropout and allowing therapists to calibrate
their treatment focus to better meet the needs of their patients. This
important empirical finding should have a significant impact not only on
current and future psychotherapy training programs—across treatment
approaches—but also on real-world clinical practice wherein therapists are
encouraged to draw on patients’ postsession evaluations for more effective
therapeutic outcomes.
As demonstrated by Lambert, the implementation of postsession eval-
uations in community-based settings also provides researchers with a golden
example of how to develop broad-based practice-research networks for future
research initiatives. In fact, several other practice-research networks are also
proving the utility of large-scale collaborative efforts between therapists and
researchers. For instance, the Pennsylvania Psychological Association’s
Practice Research Network (Borkovec et al., 2001) is a statewide effort to
involve therapists in the process of clinically relevant research, from formu-
lating questions to designing studies to collecting data. Furthermore, the
Penn State’s Center for the Study of Collegiate Mental Health (CSCMH,
http://www.sa.psu.edu/caps/research_center.shtml) is a national collabora-
tion in the United States among more than 125 university counseling cen-
ters to gather clinical data using a common set of instruments. The initial
pilot study of the CSCMH, in which 66 counseling centers contributed
one semester’s worth of data, yielded a sample of more than 20,000 cases.
Although projects of this magnitude require considerable time, coordina-
tion, and organization to even get off the ground, their potential benefits
outweigh the efforts involved.
Additionally, representing a wide range of treatment approaches,
Greenberg, Strupp, and Luborsky have cogently argued that traditional (i.e.,
comparative) treatment outcome studies have failed to provide definitive
answers about the specific mechanisms of change that are causal to therapeu-
tic outcomes. With the exception of dismantling, additive, or parametric
designs, comparative treatment trials do not provide empirical validation of
the treatment interventions so carefully spelled out in RCT treatment manu-
als (Borkovec & Castonguay, 1998). As a consequence, there has been an
increasing call for the assessment of therapist and patient factors, within and
across sessions, that may be able to provide at least approximate causal expla-
nations for specific therapy outcomes (Kazdin, 2008). The immediate future
seems to offer an opportunity for experiential/humanistic, integrative, inter-
personal, psychodynamic, and CBT process researchers—many of whom have
had a strong presence within SPR and have contributed to this book—to con-
tinue to focus their expertise on evidence-based treatments, for the identifica-
tion and measurement of mechanisms of change operating in their respective
therapy approaches.
356 ANGUS ET AL.

FROM PROCESS TO PROCESS-OUTCOME STUDIES
AND THE IDENTIFICATION OF KEY MECHANISMS
OF CHANGE IN EVIDENCE-BASED THERAPY APPROACHES
Beginning with early investigations of generic change processes and rela-

tionship conditions (Rogers, Strupp, Orlinsky, Howard), many of the seminal
researchers in this volume addressed specific measurement issues (Elkin,
Kiesler, Elliott, Stiles), sometimes by utilizing observational tools that mea-
sure at a detailed level (Benjamin, Elliott, Jones) and at other times through
qualitative research strategies that prize patients’ first-person accounts of expe-
riences of change (Hill, Elliott). It is clear that psychotherapy process research
methodologies have significantly changed over time. In particular, there has
been a gradual shift to more specification of individual change processes
observed and assessed within and across therapy sessions and an increasing
focus on tools that capture the patient’s experience of therapy. For instance,
Grawe used therapy spectrum analyses to formulate empirically validated
heuristics that specified a mixture of resource- and problem-focused interven-
tions suited to the different phases of therapy and guided the therapist’s
session-to-session decisions for the continual adaptation of treatment proce-
dures. The Client Experiencing Scale (Gendlin), Rice’s Client Vocal Quality
Scale, Stiles’s Verbal Response Modes, and Hill’s efforts to measure therapist
intentions and response modes, as well as patient reactions and behaviors, all
share an appreciation of the multifaceted ways in which language can and does
play a role in the change process.
Additionally, because most—if not all—of these measures emerged from
the intensive, inductive analysis of actual therapy sessions, they have had con-
siderable impact on clinical practice. For instance, Rice’s systematic, intensive
case analysis of specific client vocal markers (1967) ultimately contributed to
the development of a new, process directive approach to conducting human-
istic psychotherapy, emotion-focused psychotherapy. The intensive single-
case analyses of actual therapy sessions—as demonstrated by Orlinsky,
Rice, Rogers, Hill, Stiles, Elliott, and Kächele in their respective research
programs—may in fact serve as an important first step and methodological
bridge for future psychotherapy researchers who are interested in identifying
evidence-based mechanisms of change. Specifically, the possibility of conduct-
ing multiple, intensive single-case analyses of dyads that have participated in
RCTs opens the door to the identification (and with enough multiple cases,
possibly verification) of key mechanisms and/or core principles of change for
clients and therapists who have achieved clinically significant change at ther-
apy termination. The intensive, contextual analysis of key change processes—
interpersonal, patient, and therapist factors—within and across therapy
sessions in turn provides researchers with an opportunity to develop a much

more differentiated understanding of the complex factors that contribute to
productive patient outcomes in the context of evidence-based therapy prac-
tices. Importantly, these findings may then inform the development of prac-
tice guidelines and training programs for the effective implementation of
evidence-based approaches in community settings—an important and chal-
lenging future direction for psychotherapy research and practice.
Methodological flexibility that embraces a creative openness to unex-
pected findings is a recurring theme that seemed to define many of the process
and outcome researchers included in this book. When one set of research
tools proved inadequate to illuminate answers to research problems, they
were flexible enough to consider alternative approaches. The problems that
these researchers were studying were quite complex, and as complexity per se
appeared to explain particular research findings, these researchers applied
methods that were better suited for capturing this complexity.
For instance, Strupp began his career using analog procedures to make
inferences about psychotherapy, then conducted carefully designed experi-
ments using actual clients before turning to case study methodology to explore
puzzling findings from Vanderbilt I. Findings from the intensive case analyses
of actual therapy sessions in turn facilitated the development of hypotheses
used for a new RCT about training. Kächele’s intensive analysis of psycho-
analytic therapy sessions also involved a hybrid approach that mixed various
levels of observation, ranging from group-level measures to detailed and com-
plicated analyses at the level of the individual word. Stiles turned to qualita-
tive strategies in order to identify assimilative processes, whereas Hill adapted
qualitative methods to understand more fully what clients experience during
therapy sessions. Similarly, Greenberg turned to task analysis when he needed
to identify specific change processes entailed in productive empty-chair and
two-chair interventions. It is clear that the capacity to flexibly adapt standard
research methodologies for the evaluation of emerging research questions has
been key to the generation of new knowledge and effective intervention prac-
tices that have significantly affected the field as a whole.
It is also important to note that key research innovators such as Rogers,
Luborsky, Goldfried, Strupp, Beck, and Greenberg have all practiced as
psychotherapists throughout the course of their highly generative research
careers. Understanding the essential contributions of therapy practice for the
development of innovative, generative psychotherapy research programs must
continue to inform how we educate and train future generations of psychother-
apy researcher–practitioners.
While the first generation of outcome researchers saw little or no need
to address within- and across-session change processes, it can also be said that
process researchers (Kiesler, Rice, Gendlin, Rogers) were not initially inter-
ested in evaluating session or treatment outcomes when undertaking intensive
358 ANGUS ET AL.

process analyses of therapy sessions. The two worlds of psychotherapy research
began to move closer together, however, when outcomes among different ther-
apy approaches were found to be equivocal and could not be explained.
Building on the integration of psychotherapy process and outcome research
methodologies, researchers have become increasingly interested in under-
standing of the contributions of the therapeutic relationship to overall ther-
apy outcomes at treatment termination and follow-up. Orlinsky and Howard’s
Therapist Session Report, Strupp’s Vanderbilt Psychotherapy Process Scale,
and Luborsky’s Penn Helping Alliance Scales have set the stage for the devel-
opment of the many alliance measures that have both sprouted and become
deeply rooted throughout treatment research during the past generation.
In turn, the broad-based administration of reliable, pantheoretical self-
report measures of the therapeutic alliance (Bordin, Luborsky), such as the
Working Alliance Inventory (Horvath & Greenberg, 1989), has resulted in
accumulating research evidence that patients’ reports of a strong, collabora-
tive alliance early in therapy are consistently correlated with overall positive
therapeutic outcomes, across diagnostic subgroups (dysphoria, personality,
anxiety, substance abuse) and therapy approaches (client-centered, psycho-
dynamic, interpersonal, emotion-focused, CBT; Castonguay & Beutler, 2006).
However, given the consistently modest effect sizes across diagnostic samples
and therapy approaches, several researchers have cautioned that we still do not
understand if a strong, early alliance is an essential “glue” of therapy that acti-
vates and helps to sustain other change processes or if it is the fundamental
ingredient of therapeutic change itself (A. O. Horvath, personal communica-
tion, 2008). Investigating this research question and understanding how ther-
apists help clients engage in the fundamental tasks of therapy will be an
important focus of future process and outcome research that will likely influ-
ence psychotherapy training and clinical practice.
Recent developments in computerized DVD-based software systems that
enable the simultaneous coding and analysis of relational processes occurring
during therapy sessions may contribute to future research efforts addressing the
contributions of client and therapist interpersonal processes for effective ther-
apeutic outcomes. It is now possible for psychotherapy researchers to inten-
sively investigate microlevel, interpersonal process patterns that are associated
with positive, early alliance ratings, as well as therapeutic gains, using these
observer-based coding systems. The development of new coding methodologies
may in fact open the door to future innovative applications of standardized
measures such as Benjamin’s Structural Analysis of Social Behavior and the
Client Experiencing Scale (Gendlin), as well as further refinement of concepts
such as the therapeutic alliance. As demonstrated by Kächele’s textual analy-
sis of long-term psychodynamic therapy sessions, computer-assisted technology
has already made a significant impact on psychotherapy process research, and

advances in voice recognition and text conversion software may one day soon
allow for live computer analysis of text and the potential for immediate feed-
back to therapists and trainees.
THERAPIST CONTRIBUTIONS, PSYCHOTHERAPY TRAINING,

AND INTERNATIONAL RESEARCH NETWORKS
Interestingly, psychotherapy research has focused mainly on treatment

methods and on clients’ characteristics, in-session behaviors, and clinical
outcome—while the person of the psychotherapist has remained largely unex-
plored. To address this gap in the research literature, Orlinsky and colleagues
recently cofounded the SPR Collaborative Research Network (CRN) to con-
duct an international study of the development of psychotherapists. Meeting
intensively before and after SPR conferences, a group of colleagues from differ-
ent countries, professional backgrounds, and theoretical orientations worked
together to construct the Development of Psychotherapists Common Core
Questionnaire (DPCCQ). The DPCCQ has been translated into 20 languages
to date and has been used in more than two dozen countries to collect reports
about work experiences and professional development from nearly 9,000 psy-
chotherapists. A theoretical integration of research findings resulted in a
“cyclical-sequential model of psychotherapist development” that has resulted
in empirically grounded recommendations for clinical training, supervision,
and therapeutic practice. Orlinsky and his CRN colleagues are expanding data
collection in previously unstudied Western and non-Western countries, exam-
ining the distinctive characteristics shared by therapists of specific orientations
and exploring aspects of therapists’ personal lives, such as the nature and impact
of their religious background and experiences.
In addition, Bruce Wampold’s (2001) work has exerted considerable
influence on the field, emphasizing the importance of therapist, relational, and
contextual factors in psychotherapy outcome and calling into question many
of the assumptions of RCTs. Like Frank and Garfield before him, Wampold also
questions the supposition that technical factors are largely responsible for
change. As multilevel modeling and other similar statistical techniques become
more widely accepted, understood, and utilized, researchers will be able to make
continued advances in determining the relative contributions of these factors
to treatment outcomes.
Taken as a whole, the CRN project presents the field of psychotherapy
research with a highly innovative demonstration of the rich possibilities that
may ensue when broad-based international research collaborations are created
to address key research questions central to psychotherapy training and
360 ANGUS ET AL.

practice. We anticipate that SPR will continue to serve, as it has served in
the past, as a key international forum for the creation of collaborative
research networks that foster the development of innovative, rigorous
research methods, measures, and research strategies that result in more
effective training and delivery of evidence-based clinical interventions in
community-based settings.
The CRN initiative dovetails with a growing interest in the psy-
chotherapy research field at large regarding the contributions of psycho-
therapy supervision and training for effective therapeutic outcomes. Developing
methods to systematically measure core competencies and productive train-
ing outcomes will be critical for this future research initiative. Additionally,
Goldfried has also highlighted the critical importance of more fully address-
ing sexual orientation issues when educating psychotherapy researchers
and practitioners, and he has organized a curriculum review initiative to
achieve this outcome. In so doing, he has set the stage for future psy-
chotherapy researchers to continue to attend to key multicultural issues
such as race, gender, and nationality when conducting psychotherapy
research investigations.
CONCLUSION
The field of psychotherapy research has been generative—and

regenerative—in an almost benevolent way. The extraordinary scholars
featured in this book are more than researchers and/or practitioners—they are
also committed mentors, giving of themselves and their accumulated wisdom
for the benefit of the profession and, more immediately, for those who are
fortunate enough to study and work directly with them. Many of the chapter
authors, and indeed the editors of this volume, can trace their own lineage
to contributors featured in this book who were instrumental in introducing
them to SPR at early points in their professional careers. The origination of
our own collaborative research programs can be directly traced back to early
engagement in SPR meetings and the respect for diversity, intellectual
curiosity, and methodological rigor that permeates the society as a whole.
And in this regard, it seems to us that SPR is unique in its explicit nurturing
and valuing of collaborative research initiatives and its support for students
and young scholars. We are truly indebted to those who have come before
us, especially SPR cofounders David Orlinsky and Ken Howard, and this
debt of gratitude is willingly paid in the form of a commitment to mentoring
the next generation of psychotherapy researchers and ensuring the vitality
and generativity of SPR for generations to come.

REFERENCES
Barkham, M., Stiles, W., Connell, J., Twigg, E., Leach, C., Lucock, M., . . . Angus, L.
(2008). Effects of psychological therapies in randomised trials and practice-based
studies. British Journal of Clinical Psychology, 47, 397–415. doi:10.1348/0144665
08X311713
Bergin, A. E., & Garfield, S. L. (Eds.). (1978.) Handbook of psychotherapy and behav-
ior change: An empirical (2nd ed.). New York, NY: Wiley.
Borkovec, T. D., & Castonguay, L. G. (1998). What is the scientific meaning of
“Empirically Supported Therapy”? Journal of Consulting and Clinical Psychology,
66, 136–142. doi:10.1037/0022-006X.66.1.136
Borkovec, T., Echemendia, R. J., Ragusea, S. A., & Suiz, M. (2001). The Pennsylvania
Practice Research Network and future possibilities for clinically meaningful and
scientifically rigorous psychotherapy effectiveness research. Clinical Psychology:
Science and Practice, 8, 155–167. doi:10.1093/clipsy/8.2.155
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that
work. New York, NY: Oxford University Press.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of
Consulting Psychology, 16, 319–324. doi:10.1037/h0063633
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Work-
ing Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. doi:10.
1037/0022-0167.36.2.223
Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to
bridge clinical research and practice, enhance the knowledge base, and improve
patient care. American Psychologist, 63, 146–159. doi:10.1037/0003-066X.63.3.146
Lambert, M .J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research: Using
patient outcome to enhance treatment effects. Journal of Consulting and Clinical
Rice, L., & Wagstaff, A. K. (1967). Client vocal quality and expressive styles as indexes
of productive psychotherapy. Journal of Consulting Psychology, 31, 557–563.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods and findings.
362 ANGUS ET AL.

INDEX
AABT. See Association for the Advance- Assessment instruments, 71, 83–84,
ment of Behavior Therapy 119. See also specific instruments
ABCT. See Association for Behavioral Assimilation of Problematic Experiences
and Cognitive Therapies Sequence (APES), 301–302
Academy of Cognitive Therapy, 71 Association for Behavioral and Cognitive
Accurate Empathy (AE) Scale, 274 Therapies (ABCT), 6, 70
Action research, 30 Association for the Advancement of
Action stage (helping skills model), 157 Behavior Therapy (AABT), 6–7,
Adjudication model (for HSCED), 288 69
AE (Accurate Empathy) Scale, 274 Attachment, 254
AFFIRM: Psychologists Affirming Their Attitudes and Expectations form
Gay, Lesbian, and Bisexual Family, (of TDCRP), 84
135–136 Audiotaping, of therapy sessions, 21,
African Americans, 260, 262–263 272
Agnew Relationship Measure (ARM), Auditory hallucinations, 226
303 Austen Riggs Center, 334
Aiglé Foundation, 326
Alliance, measurement of, 303. See also Bandura, Albert, 102
Therapeutic alliance; Working Barrett-Lennard Relationship Inventory,
alliance 22
American Association of Applied and Beck, Aaron T., 42, 63–72
Preventive Psychology, 78 accomplishments, 67–71
American Psychiatric Association, 63, early beginnings, 66–67
324 legacy of, 72
American Psychoanalytic Association, 55 major contributions, 64–66
American Psychological Association Beck Depression Inventory, 71
(APA), 6, 34, 192, 240 Beck Institute, 71
American Psychological Foundation, 325 Begin and Garfield’s Handbook of Psycho-
American Psychological Society, 63 therapy and Behavior Change
Anaclitic form of depression, 329, 332, (Michael J. Lambert), 147
333 Behavioral analyses, 116, 117
Antipositivist revolution, 24 Behaviors
Anxiety disorders, 70, 132 common interactional, 225–226
APA. See American Psychological of therapists, 80, 81, 106
Association Behavior therapy, 4–5, 64, 102, 131. See
APA Presidential Task Force on also Cognitive–behavioral therapy
Empirically Supported Therapy Beliefs, 63, 64, 67–70
Relationships, 136 Benjamin, Lorna Smith, 221–229
APA Research Committee, 136 achievements, 224–229
APES (Assimilation of Problematic and Edward S. Bordin, 204–205
Experiences Sequence), 301–302 early beginnings, 222–224
Approval, need for, 334 legacy of, 229
ARM (Agnew Relationship Measure), major contributions, 221–222
303 Bergin, Allen E., 7, 101–109
Army, 312 early beginnings, 102–103
363
Bergin, Allen E., continued CBT. See Cognitive–behavioral therapy
and Sol L. Garfield, 310, 311, 313, CCRT. See Core conflictual relationship
315 theme
and Kenneth I. Howard, 91 Center for Cognitive Therapy, 69, 71
involvement in Society for Psycho- Center for Studies of the Person, 24
therapy, 109 Center for the Study of Collegiate
and Michael J. Lambert, 142–145, 148 Mental Health (CSCMH), 356
major accomplishments, 103–107 Central relationship patterns, 40
research on religion, psychotherapy, Centre National de la Recherche
and mental health, 107–109 Scientifique, 261
and Hans Strupp, 56 Change
Berkeley Psychotherapy Research Project, clinically significant, 146–147
262–263 cognitive information-processing
Beutler, Larry E., 7, 319–327 paradigm of, 177
accomplishments, 322–325 and emotional processes, 189
early beginnings, 320–322 and empathy, 274
legacy of, 326 Change mechanisms
major contributions, 319–320 Irene Elkin, 83–84
other contributions, 325–326 in evidence-based therapy, 357–360
Bipolar disorder, 70 William E. Piper, 341–342
Bisexual issues. See Lesbian, gay, and Laura Rice, 176–177
bisexual issues and treatment outcomes, 354–356
Blatt, Sidney J., 329–336 Change process
accomplishments, 332–335 Larry E. Beutler, 319
early beginnings, 330–332 Edward S. Bordin, 199
influences on, 335–336 Robert Elliot, 283, 287–288
legacy of, 336 Marvin R. Goldfried, 134
major contributions, 329–330 Klaus Grawe, 120–121
Bond, therapeutic, 92 Leslie Greenberg, 189
Bordin, Edward S., 199–207 Enrico Jones, 266
early beginnings, 200–201 and language, 357
and Leslie Greenberg, 190 David A.Shapiro, 274
legacy of, 206–207 Changing Frontiers in the Science of
and Lester Luborsky, 46–47 Psychotherapy (Allen E. Bergin
major contributions, 201–206 and Hans Strupp), 105
other accomplishments, 206 Checklist of Interpersonal Transactions
Bowlby, John, 223 (CLOIT), 215
Brief structured recall (BSR), 283, 287 Chestnut Lodge, 54
British Psychological Society, 271 Chicago Conference on Training in
BSR. See Brief structured recall Clinical Psychology, 314
Butler, J. M., 175, 176 Chicago Counseling Center. See Coun-
Butler-Haig Q-Sort measure of self- seling Center of University of
concept congruence/ Chicago
incongruence, 22 Child Study Department of Rochester
Society for the Prevention of
Canadian Group Psychotherapy Cruelty to Children, 20
Association, 346 Classical functional behavioral analysis,
Case formulation, comparative studies 116, 117
of, 115–117 Client-centered therapy. See also Person-
CB (cognitive behavioral) insight events, centered therapy
286 Allen E. Bergin, 102
364 INDEX
Klaus Grawe, 116 Cognitive developmental model
Leslie Greenberg, 188, 191–192 (of personality), 330
Michael J. Lambert, 142 Cognitive information-processing
Laura Rice, 176–177 paradigm (of change), 177
David A. Shapiro, 274 Cognitive morphology research, 330, 333
Client-Centered Therapy (Carl Rogers), Cognitive theory, 63, 64
21, 178 Cognitive therapy
Client Experiencing Scale, 357, 359 Aaron T. Beck, 65–66, 69
Clients. See also Patients Irene Elkin, 82, 83
engagement of, 179 Jerome Frank, 33
experiencing by, 167–170, 189 Cognitive Therapy Scale, 71
insight/insight events of, 156, 286, Collaborations (collaborative therapy
353 research)
intersession experiences of, 237 Allen E. Bergin, 104–105
perceptions of therapy process by, 285 Klaus Grawe, 118
reactions of, 156 Collaborative Research Network
session evaluations of, 303 (CRN), 237–240, 360, 361
vocal quality of, 179, 357 Collaborative Study Psychotherapy
Client–therapist mutuality, 205 Rating Scale (CSPRS), 82
Client variables, 311 Color blindness, 263
Client Vocal Quality Measure, 179 Columbia University (Teachers College),
Clinical constructs, measurement of, 342
102, 106, 108
Clinically significant change, 146–147
Common factors model (nonspecific vs.
Clinical outcome (in Generic Model of
specific factors)
Psychotherapy), 239
Jerome D. Frank, 32–36
Clinical psychology
Sol L. Garfield, 311, 314
Sol L. Garfield, 309, 310
Marvin R. Goldfried, 134
Marvin R. Goldfried, 130
Klaus Grawe, 107
scientific basis for, 52
Michael J. Lambert, 149
David A. Shapiro, 278–279
Clinical psychotherapy Lester Luborsky, 41
Larry E. Beutler, 323–324 Hans Strupp, 52–53, 56–57, 59
and research, xviii–xix Common interactional behaviors,
Clinical support tools, 146 225–226
Clinical trials, 81–82, 85. See also Communication
Randomized clinical trials interpersonal, 211, 217–219
CLOIT (Checklist of Interpersonal meta-, 218
Transactions), 215 nonverbal, 211
Coding, 214, 359 Communications analysis, 214–217
Cognitive–affective behavior therapy, Comparative studies of psychotherapy
133 Irene Elkin, 81
Cognitive–affective functioning, 176, Klaus Grawe, 118–119
177 Lester Luborsky, 41
Cognitive affective model David A. Shapiro, 275–277
(of personality), 333 Comprehensive process analysis (CPA),
Cognitive behavioral (CB) insight 283, 286–288
events, 286 Computer-aided text analyses, 252
Cognitive–behavioral therapy (CBT), 8 Computer-assisted technology, in
Marvin R. Goldfried, 129, 131–133 process research, 359–360
Enrico Jones, 265–266 Conceptual Level Scale, 333
David A. Shapiro, 272, 275–276 Conceptual stage (personality), 333
INDEX 365
Concrete perceptual stage (personality), RCT-based therapy for, 354
333 David A. Shapiro, 277, 279
Conflict resolution, 193 Depressive Experiences Questionnaire
Conjoint experience dimensions (in (DEQ), 333
Psychotherapy Session Project), Deterioration effect
237 Allen E. Bergin, 105–106
Consensual qualitative research (CQR), Michael J. Lambert, 146–147, 149
159, 287 Development, of psychotherapists,
Consistency theory, 120–121 237–239, 360
Contertransference, 9 Development of Psychotherapists
Context (in comprehensive process Common Core Questionnaire
analysis), 286 (DPCCQ), 238, 360
Contract, therapeutic, 91 DGPs (German Society for Psychology),
Core conflictual relationship theme 121
(CCRT), 40, 46 Diagnostic and Statistical Manual of
Counseling, psychotherapy and, 202–203. Mental Disorders (DSM), 43, 44
See also Clinical psychology Diagnostic and Statistical Manual of
Counseling Center at University of Mental Disorders, 4th Ed.
Michigan, 206 (DSM–IV), 222
Counseling Center of University of Differentiation–Relatedness Scale, 333
Chicago, 21, 22, 165, 166, 178 Distress, 193
Couples therapy, 186, 192–194 Dittmann, Allen, 80, 202
CPA. See Comprehensive process Dodo bird verdict, 45, 300
analysis Dose–effect (dose–response model), 9
CQR. See Consensual qualitative Kenneth I. Howard, 92–94
research David A. Shapiro, 278
CRN. See Collaborative Research William B. Stiles, 301
Network DPCCQ. See Development of Psycho-
Cross-theoretical collaborations, 118 therapists Common Core
CSCMH (Center for the Study of Questionnaire
Collegiate Mental Health), 356 DRAW model (of dream interpretation),
CSPRS (Collaborative Study Psycho- 158
therapy Rating Scale), 82 Dreams
Cultural–intellectual view, of psycho- Aaron T. Beck, 68
therapy research, 3–4 Allen E. Bergin, 102
Culture-specific measures, 260 Clara E. Hill, 156, 158
Dropout rates, 145
Depression. See also Treatment of DSM. See Diagnostic and Statistical
Depression Collaborative Manual of Mental Disorders
Research Program (TDCRP) DSM–IV (Diagnostic and Statistical
Aaron T. Beck, 64, 65, 68, 70 Manual of Mental Disorders,
Larry E. Beutler, 320, 323–324 4th ed.), 222
Sidney Blatt, 329–330, 332–333 Dysfunctional Attitudes Scale, 71
Robert Elliot, 284
Robert Elliott, 289, 290 Eating disorders, 70, 253–254
Jerome Frank, 33 Eclectic–integrative therapy, 285
Eugene Gendlin, 169 Eclectic therapy, 134
Leslie Greenberg, 186, 191–192 Editorial (journal) contributions
Donald Kiesler, 216–217 Aaron T. Beck, 70–71
Leeds Depression Project, 279 Larry E. Beutler, 325–326
postnatal, 254 Eugene Gendlin, 171
366 INDEX
Marvin R. Goldfried, 136 Engagement, of clients, 179
Clara Hill, 159 Equivalence paradox, 300–301
Enrico Jones, 267 Erikson, Eric, 42, 67
Michael J. Lambert, 147 Errors, Type I, 97
David A. Shapiro, 279–280 EST (empirically-supported treatment)
William B. Stiles, 303 movement, 8, 9
Effectiveness research. See also Outcome Ethnic matching, of therapist and
research; Process–outcome patient, 262–263
research and studies Events-based research paradigm, 186
patient-focused research vs., 95 Evidence-based therapy
personality in, 334, 335 Allen E. Bergin, 107
EFT. See Emotion-focused therapy Kenneth I. Howard, 96
EFT-C (emotion-focused therapy for mechanisms of change in, 357–360
couples), 192–194 Evocative unfolding technique, 180
Elkin, Irene, 25, 77–86, 354 Evoking messages, 215
accomplishments, 80–85 Expected treatment response, 95
and Edward S. Bordin, 199, 203 Experiences, of clients and therapists,
early beginnings, 79–80 90–91, 235–237
legacy of, 85–86 Experiencing
major contributions, 78 Eugene Gendlin, 167–170
and TDCRP, 8 Marvin R. Goldfried, 132–133
Elliott, Robert, 175, 283–291, 303 Leslie Greenberg, 189
accomplishments, 285–290 Experiencing Scale, 168–170
early beginnings, 284–285 Experiential phenomenology theory,
and Leslie Greenberg, 186, 191 166–167
legacy of, 291 Experiential therapy, 22, 25, 26
professional accomplishments, Experimental case study approach, 106
290–291 Exploration stage (of helping skills
and David A. Shapiro, 275, 277, 280 model), 157
and William B. Stiles, 301 Expressive Stance Measure, 179
Ellis, Albert, 71, 108, 109 Externalizing vocal quality, 179
Emotional experiencing, 132–133 Eysenck, Hans
Emotional injuries, 192 on effectiveness of psychotherapy,
Emotional processes, 186, 189–191 104, 353
Emotional vocal quality, 179 in history of psychotherapy, 5–6
Emotion-focused therapy (EFT), 186, and Donald Kiesler, 213
189–194. See also Process– and Lester Luborsky, 43
experiential psychotherapy
(PE-EFT) Families, working alliance in, 206
Emotion-focused therapy for couples Feedback, 355–356
(EFT-C), 192–194 Klaus Grawe, 119–120
Empathy, 9, 274, 278 Michael J. Lambert, 146–147, 149
Empirically-based research (empiricism) Fetzer Institute, 222
Aaron T. Beck, 65–66 Figuration analysis, 119
Larry E. Beutler, 325 Focused vocal quality, 179
Irene Elkin, 79 Focusing Institutes, 166
Kenneth I. Howard, 95–96 Focusing-oriented psychotherapy, 170
in psychology, 3–4 Forgiveness, 186
Empirically-supported treatment (EST) Frank, Jerome D., 29–36, 354
movement, 8, 9 accomplishments, 30–36
Encompassing frameworks, 278 early beginnings, 29–30
INDEX 367
Frank, Jerome D., continued Grawe, Klaus, 113–122
in history of psychotherapy, 5 accomplishments, 115–121
and Michael J. Lambert, 148 early beginnings, 114–115
legacy of, 36 and Eugene Gendlin, 170
and Hans Strupp, 54, 56 involvement in professional
Frank, Julia B., 32 organizations, 121
Freud, Sigmund, 3, 19, 42, 48, 52, 54, and Horst Kächele, 253, 255
64, 71, 331 legacy of, 121–122
Fromm-Reichman, Frieda, 54 major contributions, 114
Functional behavioral analysis, classical, Greenberg, Leslie, 7, 9, 185–194
116, 117 accomplishments, 188–194
early beginnings, 187–188
Garfield, Sol L., 309–316 and Robert Elliot, 285, 289
accomplishments, 313–315 and Eugene Gendlin, 169
and Allen E. Bergin, 101–103 major contributions, 185–186
and Larry E. Beutler, 321, 322 and Laura Rice, 175, 176, 180
early beginnings, 311–313 task analysis of, 358
and Kenneth I. Howard, 91 Group psychotherapy, 340–341, 343, 345
influences of, 315–316 Growth, personal, 299
and Michael J. Lambert, 145, 148 Growth collaboration and Growth
legacy of, 316 Collaborators, 205, 228
major contributions, 310–311
Gay issues. See Lesbian, gay, and bisexual Hallucinations, auditory, 226
Handbook of Psychotherapy and Behavior
issues
Change (Allen E. Bergin and Sol
Gendlin, Eugene, 24, 165–171
L. Garfield), 7, 354
accomplishments, 166–167
Allen E. Bergin and, 101, 103, 109
early beginnings, 166
Sol L. Garfield and, 310, 311, 313,
and Irene Elkin, 79, 80
315
and Leslie Greenberg, 188
Kenneth I. Howard and, 91
legacy of, 171
Michael J. Lambert and, 142–143, 145
other contributions of, 171 David E. Orlinsky and, 233, 239
psychotherapy research of, 167–170 Health–Sickness Rating Scale (HRSR),
Generativity, 84–85 43–44
Generic Model of Psychotherapy Helping alliance, 46
Kenneth I. Howard, 91–92 Helping skills, 154, 157–158
David E. Orlinsky, 239–240 Hermeneutic single case efficacy design
German Society for Psychology (DGPs), (HSCED), 283, 287
121 Hill, Clara E., 153–160, 358
Germany, 247–248 accomplishments, 155–160
Gestalt therapy, 190 early beginnings, 154–155
Gift of love hypothesis, 228 and Robert Elliot, 287
Global Assessment of Functioning, 44 and Eugene Gendlin, 168
Goal attainment, 186 influences, 160
Goldfried, Marvin R., 129–137, 354, 361 legacy of, 160
early beginnings, 130–131 major contributions, 153–154
legacy of, 137 and William B. Stiles, 303
major contributions, 131–136 Horney, Karen, 284
other accomplishments, 136–137 Howard, Kenneth I., xvii, 9, 89–98
and David A. Shapiro, 277, 280 analyses of research data, 97–98
and Hans Strupp, 51 and Lorna Smith Benjamin, 223
368 INDEX
and Sidney Blatt, 326, 361 Interaction structure theory, 266–267
dose-effect and outcome phase Internal dialogue, of patients, 68
models, 92–94 Internalized love, 228
early influences, 90 International Focusing Society, 171
empirical basis for mental health International Psychoanalytic
service policy, 95–96 Association, 267
Generic Model of Psychotherapy, International research networks,
91–92 360–361
and Michael J. Lambert, 148 Interpersonal Circle taxonomy, 215
Northwestern–Chicago Psycho- Interpersonal communication model,
therapy Research Program, 92 211, 217–219
and David E. Orlinsky, 234–237, 239 Interpersonal process recall procedure,
patient-focused research model and 285
expected treatment response Interpersonal reconstructive therapy
work, 94–95 (IRT), 221, 227–229
research on patients’ and therapists’ Interpersonal relating and relationships,
experiences in therapy, 90–91 225–227, 299
Society for Psychotherapy Research Interpersonal theory and therapy, 8
and, 6, 84 Irene Elkin, 82, 83
HRSR (Health–Sickness Rating Scale), Marvin R. Goldfried, 134–135
43–44 Donald Kiesler, 215–217
HSCED. See Hermeneutic single case Hans Strupp, 53
efficacy design Intersession Experience Questionnaires
Humanistic psychotherapy (humanism), (IEQs), 237
5 Interventions, matching patients and
Leslie Greenberg, 186, 188 Larry E. Beutler, 320, 322–323
Michael J. Lambert, 144 William E. Piper, 341, 344–345
Carl Rogers, 25 Interview types, of therapists, 178–179
Intrapersonal focus, of therapists, 135
IEQs (Intersession Experience Introjective form of depression,
Questionnaires), 237 329–330, 332–335
Illinois Psychological Association, 234, IRT. See Interpersonal reconstructive
315 therapy
IMI (Impact Message Inventory), 215
Impact Message Inventory (IMI), 215 Jones, Enrico, 259–268
Impact messages, 215 accomplishments, 262–267
Individual differences, social aspects of, beginnings, 260–262
259, 262 legacy of, 267–268
Input variables (in Generic Model of major contributions, 259–260
Psychotherapy), 91, 239 Journals, xviii, 7. See also Editorial
Insight (insight events), 156, 286, 353 (journal) contributions
Insight stage (helping skills model), 157 Justice, social, 30
Institute of Medicine, 63
Institute of Psychiatry, London, 273 Kächele, Horst, 9, 247–256, 358, 359
Integration, of counseling and psycho- accomplishments, 250–253
therapy, 202–203 early beginnings, 248–250
Intellectual–cultural view, of psycho- and Klaus Grawe, 118
therapy research, 3–4 influences of, 254–255
Interaction patterns legacy of, 255–256
Enrico Jones, 264–265 major contributions, 248
David E. Orlinsky, 225–226 other contributions, 253–254
INDEX 369
Kiesler, Donald, 7, 8, 211–219 Meaning bridges, 286, 301
and Edward S. Bordin, 204 Medical Research Council (MRC), 273,
early beginnings, 212 274, 278
and Eugene Gendlin, 169 Meehl, Paul, 130
legacy of, 219 Meichenbaum, Donald, 71
major accomplishments, 212–219 Menninger, Karl, 5, 143
Menninger Foundation, 46–47
Lambert, Michael J., 9, 141–150, Menninger Foundation Psychotherapy
355–356 Research Project, 42–44, 334
accomplishments, 144–148 Mental Health Foundation Psycho-
early beginnings, 142–143 therapy Initiative, 280
and Eugene Gendlin, 168 Mental health service policy, 95–96
influences of, 148 Mentoring
legacy of, 149–150 William E. Piper, 347
major contributions, 142–143 Irene Elkin, 84–85
Language, in change process, 357 Sol L. Garfield, 315–316
Leadership contributions Marvin R. Goldfried, 137
Aaron T. Beck, 70–71 Horst Kächele, 254
Robert Elliott, 290 Donald Kiesler, 219
Sol L. Garfield, 314–315 David E. Orlinsky, 234
Eugene Gendlin, 171 Laura Rice, 181
Marvin R. Goldfried, 136 William B. Stiles, 298
Clara E. Hill, 154, 159–160 Meta-analyses, 274–275
Enrico Jones, 267 Metacommunication, 218
William E. Piper, 346 Mindfulness-based approach to
David A. Shapiro, 279–280 cognitive therapy, 70
William B. Stiles, 303 Mood disorders, 345
Learning theory, 79, 102 MRC. See Medical Research Council
Leary, Timothy, 214, 215, 217, 224 Multidimensional analyses, 8–9
Leeds Depression Project, 279 Multisite clinical trials, 81–82, 85
Lesbian, gay, and bisexual issues, 129, Murray, Henry, 42, 331
135–136, 361 Myth (in common factors model), 35
Lewin, Kurt, 29–30
Limited vocal quality, 179 Narratives, 9, 250–253
Logical positivism, 4 National Committee for a Sane Nuclear
Love, internalized, 228 Policy (SANE), 30
Luborsky, Lester, 39–48 National Institute of Drug Abuse, 44
accomplishments, 43–48 National Institute of Mental Health
early beginnings, 41–43 (NIMH)
in history of psychotherapy, 6 awards from, 89
legacy of, 48 Irene Elkin and, 77, 78, 80–81,
major contributions, 39–41 83–84
Marvin R. Goldfried and, 136
Maladaptive transaction cycles, 216–217 grants from, 44, 54, 178, 191, 240
Managed care, 92, 147 in history of psychotherapy research,
Matching 7–8
of patients and treatments, 322–323, National Institute of Mental Health
341, 344–345 Clinical Research Branch, 8
of therapists and patients, 262–263 National Institute of Mental Health
Maternal deprivation, 223 Collaborative Study of Treatments
McGlenn, M. L., 287 of Depression, 25. See also Treat-
370 INDEX
ment of Depression Collaborative Outcome Questionnaire-45 (OQ-45),
Research Program (TDCRP) 142, 145, 147, 149
National Institute of Mental Health Outcome research and studies. See also
Outcome Measures Project, 206 Process–outcome research and
National Institute of Mental Health studies
Psychosocial Treatments Allen E. Bergin, 103–104
Research Branch, 8 in future of psychotherapy, 353–356
National Institute of Mental Health Sol L. Garfield, 313–314
Treatment Development and Eugene Gendlin, 168
Process Research section, 83 Leslie Greenberg, 190–191
Naturalistic clinical settings, 203 and history of psychotherapy, 4–5
Naturalistic observations, 176 Lester Luborsky, 40, 43–45
Need for approval, 334 David E. Orlinsky, 239
Negative cognitive triad, 64 Laura Rice, 179
Neuropsychotherapy research, 121 Carl Rogers, 21–22
Neuroses, 169 David A. Shapiro, 275–277
NIMH. See National Institute of Mental William B. Stiles, 300–301
Health Outpatient care, for mood and personal-
Nonspecific vs. specific factors, 52–53. ity disorders, 345
See also Common factors model Output variables (in Generic Model of
Nonverbal communication, 211 Psychotherapy), 91, 239
Normed self-monitoring scales of work
involvement, 238 Panic disorder, 288
Northwestern–Chicago Psychotherapy Paraprofessionals, 107
Research Program, 92 Patient-focused research model, 94–95
Nuclear weapons, psychological aspects Patient outcome measures, session level,
of, 30 355–356
Patients. See also Clients
Obsessive–compulsive disorder, 227 ethnic matching of therapists and,
Ontario Mental Health Foundation, 262–263
192 experiences of therapy by, 90–91,
Operationalized psychodynamic diagnosis 235–237
system, 252 interactions of therapists and, 9, 40,
Operations, therapeutic, 91 264–265
OQ-45. See Outcome Questionnaire-45 internal dialogue of, 68
Organizational structure, of psycho- intersession experiences of, 237
therapy research, 6–8 Patient–treatment matching
Organizations, involvement with. See Larry E. Beutler, 320, 322–323
Leadership contributions William E. Piper, 341, 344–345
Orlinsky, David E., xvii, 233–241, 360, PD. See Personality disorder
361 PE-EFT. See Process–experiential
accomplishments, 235–240 psychotherapy
early beginnings, 234–235 Penn Helping Alliance Scales, 359
and Eugene Gendlin, 170 Penn Psychotherapy Research Project,
and Kenneth I. Howard, 90, 92 6, 40, 43–47
and Michael J. Lambert, 148 Pennsylvania Psychological Association’s
legacy of, 240–241 Practice Research Network, 356
Society for Psychotherapy Research PEP. see Psychotherapeutiche Einzelfall
and, 6 Prozess-forschung
Outcome Measures Project, 80 Perfectionism, 334
Outcome phase model, 9, 93–94 Perls, Fritz, 188
INDEX 371
Personal growth, 299 Process research and studies
Personality, 330, 333–335 Sol L. Garfield, 309
Personality disorder (PD) Marvin R. Goldfried, 134–135
Lorna Smith Benjamin, 221–222, Clara Hill, 153, 155–156
226–227 William E. Piper, 341–342, 345–346
William B. Piper, 345 in psychotherapy field, 357–360
Person-centered therapy, 22, 25–26. Carl Rogers, 18, 21
See also Client-centered therapy David A. Shapiro, 277–278
Pharmacological treatment, 82, 83 Process Scale, 168, 170
Piaget, Jean, 117 Programmatic linguistic analyses, 9
Piper, William E., 339–348 Prototype methodology, 263–264
accomplishments, 344–346 Psychoanalytic theory, 251–253
early beginnings, 342–344 Psychodynamic interpersonal (PI)
influences of, 346–347 therapy
legacy of, 347–348 Robert Elliott, 286
major contributions, 339–342 Marvin R. Goldfried, 134–135
other contributions, 346 David A. Shapiro, 272, 275–276
PI therapy. See Psychodynamic inter- Psychodynamic theory and therapy
personal therapy Aaron Beck, 64, 68
Placebo effects, 31, 33, 142 Lorna Smith Benjamin, 221
Plan Analysis, 115, 116 William E. Piper, 339–340
Positive regard, 9 Enrico Jones, 265–266
Positivism, 4, 24, 167 Lester Luborsky, 40
Postnatal depression research, 254 Psychologists for Social Responsibility,
PQS. See Psychotherapy Process Q-set 171
Practice-based evidence, 96–97 Psychooncology research, 254
Practice-research networks, 356 Psychopathology, 225, 229
Primates, 223, 224 Psychotherapeutiche Einzelfall Prozess-
Problematic reaction points, 180, 286 forschung (PEP), 118, 253
Problem-solving training, 132 Psychotherapeutic investigations, 271
Process coding systems, 214 Psychotherapists. See Therapists
Process–experiential psychotherapy Psychotherapy, 3–10, 353–361. See also
(PE-EFT). See also Emotion- Comparative studies of psycho-
focused therapy (EFT) therapy
Robert Elliott, 284, 288–290 clinical, xviii–xix, 323–324
Leslie Greenberg, 191–192 effects of, 144, 145
Laura Rice, 175, 180–181 history of, 4–9
Process–outcome analyses, in TDCRP, 83 integration of counseling and,
Process–outcome research and studies. 202–203
See also Outcome research and intellectual–cultural view of, 3–4
studies outcome research in, 353–356
Larry E. Beutler, 322–323 process and process–outcome studies
Robert Elliott, 289 in, 357–360
Jerome D. Frank, 31–36 social factors in, 262–263
in future of psychotherapy, 357–360 therapist contributions in, 360–361
Marvin R. Goldfried, 129 Psychotherapy integration movement,
Leslie Greenberg, 185, 188–189 133–134
Enrico Jones, 265–266 Psychotherapy Process Q-set (PQS),
David E. Orlinsky, 239–240 259, 260, 263–267
Carl Rogers, 5 “Psychotherapy Recapitulates Ontogeny”
Hans Strupp, 57–58 (William B. Stiles), 299
372 INDEX
Psychotherapy Session Project, 90–91, Remoralization phase (of outcome phase
235–237 model), 93–94
Repetitive interaction structures, 260
QOR. See Quality of object relations Representational theory of personality,
Qualitative research 333, 334
Robert Elliot, 286–288 Responsiveness, 300–301
Clara E. Hill, 159, 358 Rhesus monkeys, 223
Carl Rogers, 23–24 Rice, Laura, 9, 24, 175–181
William B. Stiles, 302–303, 358 accomplishments, 178–181
Quality of object relations (QOR), Client Vocal Quality Scale of, 357
344–345 early beginnings, 177–178
Quantitative naturalistic research and Robert Elliot, 285, 286, 289
Kenneth I. Howard, 96–98 and Leslie Greenberg, 185–189, 191
Laura Rice, 178–179 legacy of, 181
Quantitative outcome measures major contributions, 176–177
(in HSCED), 287 Ritual (in common factors model), 35
Rogers, Carl, 17–26, 331
Race, 260, 262–263 accomplishments, 20–22
Randomized clinical trials, 22, 31 and Lorna Smith Benjamin, 223
William E. Piper, 344–346 and Allen E. Bergin, 102, 109
Irene Elkin, 354 and Edward S. Bordin, 200–202, 204
Sol L. Garfield, 309 early beginnings, 19–20
outcome studies based on, 354–355 and Irene Elkin, 80
Randomized Controlled Trials Commit- and Eugene Gendlin, 165, 166, 168
tee for the Canadian Institutes of and Leslie Greenberg, 188
Health Research, 346 in history of psychotherapy, 5
Rank, Otto, 20 and Kenneth I. Howard, 90
Rapaport-Klein Study Group, 335 and Donald Kiesler, 211–213
Rasch analysis, 284, 288 and Michael J. Lambert, 144, 148
Rationale (in common factors model), legacy of, 24–26
35 major contributions, 18–19
Rationalism, 4 process–outcome research, 23–24
Realism, 3–4 and Laura Rice, 175, 176, 178
Realizations, therapeutic, 92 on valuing clients, 302
Recording, of psychotherapy sessions, Rorschach test, 21, 179, 311
21, 272 Rosenzweig, Saul, 45, 48
Reductionism, 106
Regressive loyalty and Regressive SANE (National Committee for a Sane
Loyalists, 205, 228 Nuclear Policy), 30
Rehabilitation phase (of outcome phase SASB-based Intrex questionnaire, 225
model), 94 SASB model. See Structural analysis of
Relational disorders, 225 social behavior model
Relational form of depression, 329, 330, Scale for Suicide Ideation, 71
332, 333 Schemas, 64–65, 301
Relationship factors, 177 Schema Theory, 117
Relationship patterns, central, 40 Schizophrenia, 70, 80, 169. See also
Remediation phase (of outcome phase Wisconsin Schizophrenia Project
model), 94 SCID-II (Structures Clinical Interview
Remission, spontaneous, 141, 142, 144, for DSM–IV Personality
145 Disorders), 222
INDEX 373
Scientific Affairs of the American Single-case research, 357
Psychoanalytic Association, 267 Robert Elliott, 287–288
Scientific methods and standards Horst Kächele, 250–253
of Irene Elkin, 81–83 Social aspects, of individual differences,
of Hans Strupp, 55–56 262
Scientist–practitioner model, xix Social justice, 30
Self-actualization, 176 Society for Personality Assessment, 222
Self-definitional form of depression, Society for Psychopathology Research, 70
330, 332–335 Society for Psychotherapy Research
Self-disclosure, 156 (SPR)
Lorna Smith Benjamin and, 222
Self-relatedness (in Generic Model of
Allen E. Bergin and, 109
Psychotherapy), 92
Larry E. Beutler and, 321, 325
Sensitivity training groups (T-groups),
Edward S. Bordin and, 199, 204, 206
342–343
Irene Elkin and, 84
Sensorimotor-enactive stage
Robert Elliott and, 285, 290
(personality), 333 in future of psychotherapy, 360
SEPI (Society for the Exploration of Sol L. Garfield and, 310, 315
Psychotherapy Integration), Marvin R. Goldfried and, 136
133–134 Klaus Grawe and, 121
SEQ (Session Evaluation Questionnaire), Leslie Greenberg and, 190, 191
303 Clara E. Hill and, 159–160
Sequential process research paradigm Kenneth I. Howard and, 89, 98, 240
studies, 21 Enrico Jones and, 267
Serendipitous findings, 56 Horst Kächele and, 250, 254–255
Service delivery research, 278–279 Michael J. Lambert and, 148
Session Evaluation Questionnaire Lester Luborsky and, 47, 48
(SEQ), 303 origin of, 6
Session evaluations, of clients, 303 David E. Orlinsky and, 234, 240
Session level patient outcome measures, Laura Rice and, 175, 181
355–356 David A. Shapiro and, 271, 279–280
Sexual orientation. See Lesbian, gay, William B. Stiles and, 303
and bisexual issues Hans Strupp and, 55
Shapiro, David A., 271–281 Society for Psychotherapy Research
accomplishments, 274–279 Collaborative Research Network
early beginnings, 272–274 (CRN), 237–240, 360, 361
and Robert Elliott, 288 Society for the Exploration of Psycho-
therapy Integration (SEPI),
influences of, 280–281
133–134
legacy of, 281
Specificity, 31–33
major contributions, 272
Spontaneous remission, 141, 142, 144,
other contributions, 279–280 145
and William B. Stiles, 301 SPR. See Society for Psychotherapy
Sheffield Psychotherapy Projects, Research
275–278, 281, 288–289 SPRI project. See Single-case Process
Short-term forms of therapy Research project
Sidney J. Blatt, 334–335 State University of New York at Stony
William E. Piper, 340, 344–346 Brook, 131, 137
Significant events (in HSCED), 288 Statistical analyses, 97–98
Single-case Process Research (SPRI) Stiles, William B., 295–304
project, 118, 253 accomplishments, 298–303
374 INDEX
beginnings, 295–298 Theory building, 295, 298–299
and Klaus Grawe, 117 Theory of personality, 176
legacy of, 304 Therapeutic alliance, 359
qualitative strategies of, 358 Irene Elkin, 83–84
and David A. Shapiro, 275, 277, Marvin R. Goldfried, 135
278, 280 Lester Luborsky, 46
Stimulus hunger, 176 Carl Rogers, 18–19
Strong Vocational Interest Inventory, Therapeutic bond (in Generic Model of
312 Psychotherapy), 92
Structural Analysis of Social Behavior, Therapeutic change, 120–121
359 Therapeutic contract (in Generic
Structural analysis of social behavior Model of Psychotherapy), 91
(SASB) model, 221, 224–227 Therapeutic cycle model, 252
Structures Clinical Interview for Therapeutic operations (in Generic
DSM–IV Personality Disorders Model of Psychotherapy), 91
(SCID-II), 222 Therapeutic realizations (in Generic
Strupp, Hans, 6, 51–61, 358 Model of Psychotherapy), 92
accomplishments and honors, 55–59 Therapeutic relationship, 34, 59, 240
and Allen E. Bergin, 104, 105 Therapeutic setting (in common factors
early beginnings, 53–54 model), 34
and Michael J. Lambert, 148 Therapist contributions
legacy of, 59–60
in future of psychotherapy, 360–361
and Lester Luborsky, 44, 47
Hans Strupp on, 55, 57
major contributions, 52–53
Therapist-offered conditions, 144, 145
and David E. Orlinsky, 236
Therapist response modes, 155–156
Stuttgart Center for Psychotherapy
Therapists
Research, 248, 253
accounts and perceptions of, 285, 288
Subjectivity, quantification of, 9
behavior of, 80, 81, 106
Suicide, 69, 71
congruence of, 214
Suicide Intent Scale, 71
Sullivan, Henry Stack, 80, 148, 216 development of, 237–239, 360
Supervision, 150, 206 ethnic matching of patients and,
Supportive–expressive psychotherapy, 262–263
41, 46–47 experiences of therapy by, 90–91,
Symptom Checklist-90-R, 288 235–237
Symptom formation, 40 focus of, 134–135
interactions of patients and, 9, 40,
Task analysis, 9, 358 264–265
Robert Elliott, 289 intersession experiences of, 237
Leslie Greenberg, 186, 188–189 interview types of, 178–179
Laura Rice, 180 response modes of, 286
TAT. See Thematic Apperception Test responsiveness of, 117
TDCRP. See Treatment of Depression Therapist Session Reports, 359
Collaborative Research Program Therapy
Teaching Patients’ and therapists’ experiences
of focusing, 170 of, 90–91, 235–237
of helping skills, 157–158 Therapists’ perceptions and accounts
by William B. Stiles, 296–297 of, 285, 288
Temple Psychotherapy Project, 6 Therapy Session Reports (TSR), 235–237
Thematic Apperception Test (TAT), Therapy Spectrum Analysis (TSA),
21, 42, 311 114, 119–120
INDEX 375
Thompson, John, 296 University of Michigan, 200, 202, 206
Time-limited dynamic psychotherapy University of North Carolina, Chapel
(TLDP), 58–59, 145 Hill, 296–297
Topeka Project, 251 University of Pennsylvania, 42–44, 47
Topeka Psychoanalytic Institute, 42 University of Sheffield, 273–247
Training University of Utah Neuropsychiatric
by Larry E. Beutler, 326 Institute, 228–229
by Robert Elliott, 290 University of Wisconsin, 23, 25. See also
by Sol L. Garfield, 313 Wisconsin Schizophrenia Project
by Klaus Grawe, 118
Clara Hill’s study of, 157–158 Vanderbilt I and II experiments, 6,
by Lester Luborsky, 47–48 51–52, 56–59, 358
in psychotherapy field, 360–361 Vanderbilt Psychotherapy Process Scale
research methods in, 19 (VPPS), 236, 359
by David A. Shapiro, 279–281 Verbal Response Modes (VRMs),
Hans Strupp on, 59 299–300, 357
Transference interpretations, 345–346 Vertical behavioral analysis, 116, 117
Treatment of Depression Collaborative Veterans Administration, 31
Research Program (TDCRP), 8 Victor Frankl Foundation, 171
Sidney J. Blatt, 334, 335 Videotaping, of therapy sessions, 272
Visual perception, 42
Irene Elkin, 77–78, 80–86
Vocal quality, of clients, 179, 357
Enrico Jones, 265, 354
Vocal Quality Scale, 357
Carl Rogers, 25
Vocational decision-making, 199,
Treatment–patient matching. See
201–202
Patient–treatment matching
Von Uexküll, Thure, 249
Treatment response, in psychotherapy
VPPS. See Vanderbilt Psychotherapy
research, 4–6. See also Process–
Process Scale
outcome research and studies
VRMs. See Verbal Response Modes
TR-EAT project, 253
TSA. See Therapy Spectrum Analysis Wachtel, Paul, 133, 335
TSR (Therapy Session Reports), 235–237 WAI. See Working Alliance Inventory
Two-chair dialogue events, 189, 285, Washington School of Psychiatry
358 (WSP), 54
Two-configurations model, 329–334 Western Behavioral Sciences Institute,
Type I errors, 97 23–24
Wisconsin Schizophrenia Project, 22
Ulm Textbank, 249, 252 Eugene Gendlin, 165, 169
Ulm University, 9, 248–250, 252 Donald Kiesler, 211–214
Unconscious, 68 Carl Rogers, 23
Uniformity myth, 213 Working alliance, 9
University of Chicago Edward S. Bordin, 199, 201–202,
Irene Elkin, 78, 84–85 204–206
Eugene Gendlin, 165, 166 Leslie Greenberg, 190
Kenneth I. Howard, 90 Lester Luborsky, 46
David E. Orlinsky, 234–235, 240–241 Working Alliance Inventory (WAI),
Laura Rice, 175, 178 190, 303, 359
Carl Rogers, 21–22 “WOW!-effects,” 106
376 INDEX
ABOUT THE EDITORS
Louis G. Castonguay, PhD, is a professor of psychology at Penn State Uni-

versity. His work focuses on the process, outcome, and training of psychother-
apy, as well as on the development of practice–research networks. He has
coedited three books: on psychotherapy integration (with Conrad Lecomte),
on principles of therapeutic change (with Larry Beutler), and on insight in
psychotherapy (with Clara Hill).
J. Christopher Muran, PhD, is associate dean and professor, Derner Insti-

tute, Adelphi University, and director, Brief Psychotherapy Research Pro-
gram, Beth Israel Medical Center. His research has concentrated on alliance
ruptures and resolution processes and has resulted in several book collabora-
tions, including Negotiating the Therapeutic Alliance, Self-Relations in the Psy-
chotherapy Process, Dialogues on Difference, and Therapeutic Alliance.
Lynne Angus, PhD, is a professor of psychology at York University in

Toronto, Canada. She is the senior editor of the Handbook of Narrative and
Psychotherapy (with John McLeod). Her research focuses on the investigation
of narrative and emotion processes in psychotherapy, and she has developed
377
the Narrative Processes Coding System (with Heidi Levitt and Karen
Hardtke) for application in differing treatment approaches.
Jeffrey A. Hayes, PhD, is a professor of counseling psychology at Penn State

University. His scholarship focuses on the psychotherapy relationship, with
an emphasis on therapist factors and the integration of spirituality and psy-
chology. He has coauthored two books with Charles Gelso, The Psychother-
apy Relationship and Countertransference and the Therapists’ Inner Experience:
Perils and Possibilities.
Nicholas Ladany, PhD, is a professor of counseling psychology at Lehigh

University in Bethlehem, Pennsylvania. He is the author of three books on
supervision and training: Critical Events in Psychotherapy Supervision: An Inter-
personal Approach; Counselor Supervision: Principles, Process, and Practice; and
Practicing Counseling and Psychotherapy: Insights from Trainees, Clients, and
Supervisors.
Timothy Anderson, PhD, is an associate professor of psychology at Ohio

University in Athens. His current research is on the identification of com-
mon therapist factors that predict therapy processes and outcome. He is the
recipient of the 2004 Distinguished Early Career Award from the Interna-
tional Society for Psychotherapy Research.
378 ABOUT THE EDITORS

Louis G. Castonguay, J. Christopher Muran, Lynne E. Angus, Jeffrey A. Hayes, Nicholas Ladany, Timothy Anderson-Bringing Psychotherapy Research to Life_ Understanding Change Through the Work of Leading.pdf

Uploaded by

Copyright:

Available Formats

Louis G. Castonguay, J. Christopher Muran, Lynne E. Angus, Jeffrey A. Hayes, Nicholas Ladany, Timothy Anderson-Bringing Psychotherapy Research to Life_ Understanding Change Through the Work of Leading.pdf

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Louis G. Castonguay, J. Christopher Muran, Lynne E. Angus, Jeffrey A. Hayes, Nicholas Ladany, Timothy Anderson-Bringing Psychotherapy Research to Life_ Understanding Change Through the Work of Leading.pdf

Uploaded by

Copyright:

Available Formats

Bringing

American Psychological Association • Washington, DC

Typeset in Goudy by Circle Graphics, Inc., Columbia, MD

Printer: United Book Press, Baltimore, MD

Library of Congress Cataloging-in-Publication Data

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

Contributors .............................................................................................. xiii

I. Establishing the Foundation for the Scientific Study

II. Does Psychotherapy Work? .............................................................. 75

III. How Does Psychotherapy Work? ................................................. 125

B. Client Contributions.......................................................................... 163

C. Relationship Variables ...................................................................... 197

IV. What Works for Whom?................................................................ 307

J. Stuart Ablon, Massachusetts General Hospital and Harvard Medical

In describing how one of their early collaborations began, David

Like many histories, the story of psychotherapy research is one repeatedly

AN INTELLECTUAL–CULTURAL VIEW OF THE FIELD

American and British psychology has been dominated by the empirical

A BRIEF HISTORY OF THE FIELD

There have been a number of histories written about psychotherapy

4 MURAN, CASTONGUAY, AND STRAUSS

A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 5

6 MURAN, CASTONGUAY, AND STRAUSS

A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 7

8 MURAN, CASTONGUAY, AND STRAUSS

A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 9

With this chapter, we have provided a brief narrative history of psycho-

10 MURAN, CASTONGUAY, AND STRAUSS

A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 11

12 MURAN, CASTONGUAY, AND STRAUSS

A BRIEF INTRODUCTION TO PSYCHOTHERAPY RESEARCH 13

In many ways, Carl Rogers was and continues to be a figure of contra-

Often obscured by the importance and far-reaching effects of his clini-

18 ELLIOTT AND FARBER

Kirschenbaum’s (2007) biography of Rogers provides more information

Following graduation, Rogers accepted a position with the Child

20 ELLIOTT AND FARBER

Rogers’s academic career began at Ohio State University in 1939, where

Systematic, Controlled Outcome Research

In 1945, Rogers moved to the University of Chicago to establish a

Measures for Person-Centered/Experiential Therapies

A key element of systematic psychotherapy research is the use of theory-

22 ELLIOTT AND FARBER

In 1957, Rogers decided returned to his alma mater, the University of

24 ELLIOTT AND FARBER

Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in

26 ELLIOTT AND FARBER

The professional contributions of Jerome D. Frank, PhD, MD, or “Jerry,”

Psychological Issues of Nuclear Weapons

Frank’s military experience and deep commitment to social issues cre-

30 WAMPOLD AND WEINBERGER

In Search of Specificity and the Road to Common Factors

32 WAMPOLD AND WEINBERGER

The Common Factor Model

34 WAMPOLD AND WEINBERGER

Jerome Frank was a pioneer in psychotherapy research. His journeys

American Psychological Association. (1986). Awards for distinguished contributions

36 WAMPOLD AND WEINBERGER