Journal of Consulting and Clinical Psycholog' 1993. Vol.61, No.

2,306-316

Copyright 1993 h\ UK American Psychological Association Inc 0022-(>06X/93/$3.00

Comparing the Process in Psychodynamic and Cognitive-Behavioral Therapies

Enrico E. Jones and Steven M. Pulos
Archival records were used to compare the therapy process in 30 brief psychodynamic and 32 cognitive-behavioral therapies. Verbatim transcripts of 186 treatment sessions were rated with the Psychotherapy Process Q-set, designed to provide a standard language for the description of process. Results demonstrated that although some features were common to both treatments, there were important differences. Cognitive-behavioral therapy promoted control of negative affect through the use of intellect and rationality combined with vigorous encouragement, support, and reassurance from therapists. In psychodynamic psychotherapies, there was an emphasis on the evocation of affect, on bringing troublesome feelings into awareness, and on integrating current difficulties with previous life experience, using the therapist-patient relationship as a change agent. The clinical theoretical precepts underlying psychodynamic treatments received considerable support. In cognitive-behavioral therapies, there was evidence for the importance of developmental, as opposed to rationalist, intervention strategies for treatment outcome.

A theory of psychotherapy leads therapists to consider the nature and etiology of their patients' disorders in a particular way and points toward certain forms of intervention or technique. The technical prescriptions of psychodynamic and cognitive-behavioral therapies are often contradictory. For example, psychodynamic therapists are wary of the consequence of using suggestion, whereas cognitive-behavioral therapies often suggest specific in-session exercises or out-of-session activities. Important and systematic differences such as these should presumably lead to an identifiable difference in the effectiveness of treatments; however, they have not. In treatment studies, researchers have failed to demonstrate systematically the differential effects of different treatments (Miller & Berman, 1983; Smith, Glass, & Miller, 1980). The apparent paradox of lack of differential effectiveness in contrast to evident technical diversity (or outcome equivalence contrasted with content nonequivalence) has been widely noted (e.g., Stiles, Shapiro, & Elliott, 1986). Most recently, the report of the National Institute of Mental Health Treatment of Depression Collaborative Research Program noted few differences among the effectiveness of interpersonal psychotherapy,

Enrico E. Jones, Department of Psychology, University of California at Berkeley; Steven M. Pulos, Department of Psychology, University of Northern Colorado. This research was supported by National Institute of Mental Health Research Grant R01 MH 38348. Janice D. Cumming, Sarah Hall, Lesley A. Parke, Sandra Tunis, and other members of the Berkeley Psychotherapy Research Group contributed in many ways to this study. India Fleming provided comments on several drafts. Special thanks are extended to George Silberschatz, John Curtis, and Steven D. Hollon for granting access to their data archives. Correspondence concerning this article should be addressed to Enrico E. Jones, Department of Psychology, University of California, Berkeley. California 94720.
306

cognitive-behavioral therapy, and antidepressant medication in the treatment of major depressive disorder. The absence of real differences between the two psychotherapies was once again construed as support for the importance of common factors in different types of psychologically mediated treatment (Elkinetal., 1989). This has led to attempts to identify a common core of therapeutic process. It is possible, for instance, that features shared by cognitive-behavioral and psychodynamic psychotherapies underlie differences in technique and that these commonalities are responsible for the general equivalence in effectiveness. A line of research, once popular but now apparently fading, that stems from this effort was on the "therapeutic alliance" (Frieswyck et al., 1986). Most psychotherapists have not found the therapeutic alliance construct sufficient for assessing the effectiveness of their techniques or for explaining how patients change; it locates the common core at too high a level of abstraction. The question of whether the effects of therapy are the result of specific intervention strategies and techniques or the result of factors common to the various treatment approaches has fundamental theoretical import as well as practical clinical implications. Some researchers have considered the absence of differential treatment effects a failure to support, if not a refutation of, the clinical theories and models of mental functioning from which they are derived. This absence of differences has also raised questions about the limitations of controlled clinical trials in explaining how patients change through such interventions (e.g., Persons, 1991). Although comparative outcome studies can address questions of efficacy, the probative value of such studies for the treatments' underlying theoretical constructs is indirect and limited. Understanding what promotes therapeutic change requires more direct study of treatment processes. There have been few comparative studies of the psychotherapy process, and these have been conducted primarily to determine whether cognitive-behavioral therapy and interpersonal ther-

COMPARING THERAPY PROCESSES apy for depression can be discriminated (DeRubeis, Hollon, Evans, & Bemis, 1982; Luborsky & DeRubeis, 1984). The content differences in such newer manual-guided treatments have been demonstrated to be both large and systematic. However, differences in therapist technique have not been directly associated with differential effectiveness. The present study was an attempt to determine what aspects of the therapy process are different and what qualities are similar in psychodynamic and cognitive-behavioral therapies. The aim was to assess, more directly than is possible in comparative outcome studies, the validity of the clinical theories that constitute the foundation of these two approaches to psychological intervention. Two sets of archival recordsone of cognitivebehavioral treatments and one of brief psychodynamic treatmentswere obtained from other investigators. The study, which is based on the archival data, has certain limitations: There was no random assignment to treatment condition; the patient populations in the cognitive-behavioral and psychodynamic therapies varied in the kinds of diagnoses and problems they represented; half of the patients treated in cognitive-behavioral therapy also received pharmacotherapy; indeed, the two samples were not even assessed on the same treatment outcome measures. This study does not, then, constitute a formal comparative outcome study. Instead, it is an attempt involving the use of the same device, the Psychotherapy Process Q-set (Jones, 1985), to describe processes in both cognitive-behavioral and psychodynamic therapies and to identify which kinds of processes lead to patient improvement in these therapies in whatever manner patient change was measured. Method Psychodynamic Therapy Patient sample. The sample of psychodynamic treatments was obtained from the Mount Zion Psychotherapy Research Group in San Francisco. The archive contained records for 38 cases and included pre- and posttherapy evaluations obtained from patients, therapists, and clinical evaluators, as well as complete audiotape records of all treatment sessions. Four cases could not be used for reasons of confidentiality, 2 patients terminated therapy after five or six sessions, and in two cases insufficient assessment data were acquired, leaving a total N of 30 (20 female, 10 male) patients in the study sample. Approximately half of the sample were referred by mental health professionals or physicians; the other half were self-referred. Patients were assessed through both an intake interview and psychological screening tests. All patients were accepted into the study if, at the time of intake, (a) they had a history of meaningful interpersonal relationships; (b) they did not meet exclusion criteria (i.e., evidence of psychosis, organic impairment, mental deficiency, serious substance abuse or suicidal potential); and (c) it was agreed by an independent evaluator and another clinician that the subject was in need of treatment and could potentially benefit from a course of brief therapy. The mean age of the sample was 50 years (range, 20-81 years). One patient had at least some high school education, 5 patients had completed high school, 5 patients had some college, 6 patients had completed college, 8 patients had some graduate school, and 5 patients had completed doctoral degrees. Therapists and treatment. The 15 therapists in the study considered the psychodynamic model to be their primary theoretical orientation. Five therapists treated 3 patients each, five treated 2 patients each, and another five treated 1 each (total N= 30). Eight of the therapists were psychiatrists, 6 were clinical psychologists, and 1 was a psychiatric social worker; 13 were male and 2 were female. They had an average of

307

6 years of private practice experience (range, 1-19 years); all had received some specialized training in brief psychodynamic therapy. The average treatment length was 15.8 sessions. Assessment of outcome. Patient assessments were obtained at initial evaluation and at termination. Patients completed the Symptom Distress ChecklistRevised (SCL-90-R; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974), a self-report symptom inventory constructed to assess psychological and symptom status. Therapists and clinical evaluators completed the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962), which yields a 0- to 96-point symptom score. At therapy termination, patients, therapists, and evaluators all completed an Overall Change Rating (OCR), a 9-point rating scale ranging from very much worse (1) to very much improved (9). Cognitive-Behavioral Therapy Patient sample. The data for the cognitive-behavioral therapy sample were collected as part of a study to compare the effectiveness of cognitive-behavioral therapy and tricyclic pharmacotherapy, alone and in combination, in the treatment of unipolar depression (Hollon et al., 1989). The data set pertinent to the present study included treatment records of 32 patients who completed treatment in one of the two psychotherapy conditions and contained assessment data obtained from the patients themselves and from clinical evaluators as well as audio recordings of therapy sessions. The patient sample met the following criteria at intake evaluation: (a) a definite diagnosis of major depressive disorder on the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1979); (b) a score of &20 on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961); and (c) a score of >14 on the 17-item version of the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967). Exclusion criteria relating to diagnoses, drug dependency, and severe suicidal preoccupations were also applied. Patients who dropped out were replaced until a total of 16 patients per group completed the treatment protocol. Hollon et al. (1989) reported that the groups did not differ significantly with respect to dropout rates. The final sample consisted of 25 female and 7 male patients; the mean age of the sample was 33.8 years, with a standard deviation of 10.6. Three patients had some high school education, 11 had completed high school, 13 had some college, 3 had completed college, and 2 had graduate or professional training. Therapists and treatments. A clinical psychologist and three clinical social workers (3 male, 1 female) conducted the treatments. All underwent 6 to 14 months of training in cognitive-behavioral therapy, and posttraining supervision sessions were held once or twice weekly throughout the study. Each of the four therapists treated 4 patients in each of the two therapy groups. Patients in both groups were seen for a maximum of twenty 50-min sessions over a 12-week period. The study protocol called for 2 sessions per week over the first 4 weeks, either 1 or 2 sessions per week over the middle 4 weeks, and 1 session per week over the last 4 weeks. The average length of treatment was 14.4 sessions. Patients in the combined treatment group also met weekly for 20 to 50 min with a psychiatrist. These sessions focused on pharmacotherapy management and included information about the dose and possible side effects of imipramine hydrochloride. Assessment of outcome. Patient assessments were obtained before the first therapy session and again at posttreatment. Patients completed the BDI, a 21-item self-report inventory designed to assess numerous aspects of syndrome depression including affective, cognitive, and physiologic components (Beck et al, 1961); the Depression Scale (Scale 2) of the Minnesota Multiphasic Personality Inventory (MMPID; Hathaway & McKinley, 1983); and the Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980), a 30-item instrument that measures subjects' habitual negative thoughts. Two clinician-rated measures of depression were rated by indepen-

308

ENRICO E. JONES AND STEVEN M. PULOS ing from .83 to .89 for 2 raters and from .89 to .92 for 3 to 10 raters (Jones, Hall, & Parke, 1991). In a test of discriminant validity, a videotape of three therapy sessions, conducted with the same patient by well-known proponents of their respective treatment forms (Albert Ellis, Fritz Perls, and Carl Rogers), were rated by 10 therapists who represented a variety of theoretical orientations and a range of experience. Fifty-two Q-items differentiated rational-emotive from gestalt therapy, and 38 items differentiated client-centered therapy from gestalt therapy. The 10 items that were designated most and least characteristic for each form of therapy were then presented to another group of five therapists familiar with these treatment modalities, who successfully matched (p < .001) the sets of Q-items with the type of therapy from which they had been derived. This back translation of the Q-set indicates that the instrument differentiated types of therapy not only in terms of a large number of significant differences but also in a manner that accurately captured the nature of the various theoretical orientations that were represented. A series of studies has been conducted that demonstrate the instrument's capacity to identify process correlates of outcome in different patient populations and with different indices of patient improvement (Jones et al.. 1991). The relatively large number of items in the Q-set increases the possibility of making a Type I error. There is an inherent trade-off between the levels of Type I and Type 11 errors. In an exploratory study involving data difficult to obtain, it seems scientifically strategic to lessen the likelihood of Type II errors rather than overprotect against Type I errors. In a relatively open inquiry, the recognition of patterns, consistencies, and covariations by trained clinical observers using the broad set of variables represented in the Q-items allows for the discovery of important phenomena and the relations between them. Q-ratings for the present study were completed by a pool of 10 judges, research-oriented clinicians, and graduate students in clinical psychology, who received training in the application of the Q-technique. The judges represented a range of theoretical perspectives, including psychodynamic and cognitive-behavioral, although most were eclectic in their clinical orientations. The verbatim transcripts of Hours 1, 5, and 14 of each case (N of treatment sessions = 186) were completely randomized, and independent Q-ratings were made by two

dent evaluators who were blind to treatment. The Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967) assesses severity of depressive symptoms including mood, guilt, suicidal ideation, sleep disturbances, and so forth; the patient's symptoms over the past week are rated on either a 3- or a 5-point scale (total range, 0-50). The second measure, the Raskin Depression Scale (RDS; Raskin, Schulterbrandt, Reatig, & McKeon, 1970), consists of 5-point rating scales on each of three separate aspects of depression, and scores range from 3-15. Table 1 provides a summary of the two data sets.

The Psychotherapy Process Q-Set

The 100-item Psychotherapy Process Q-set furnishes a language and rating procedure for the comprehensive description, in clinically relevant terms, of the therapist-patient interaction in a form suitable for quantitative comparison and analysis. The instrument is designed to be applied to an audiotaped or videotaped record or transcript of a single treatment hour as the unit of observation. Using the psychotherapy hour in its entirety has the advantage of allowing clinical judges to study the material for confirmation of alternative conceptualizations and to assess the gradually unfolding meaning of events. A coding manual (Jones, 1985) details instructions for Q-sorting and provides the Q-items and their definitions, along with operational examples to minimize potentially varying interpretations of the items. After studying the record of a therapy hour, clinical judges proceed to the ordering of the 100 items, each printed separately on cards to permit easy arrangement and rearrangement. The items are sorted into nine piles ranging on a continuum from least characteristic (Category 1) to most characteristic (Category 9), with the middle pile (Category 5) used for items deemed either neutral or irrelevant for the particular hour being rated. The number of cards sorted into each pile (ranging from 5 at the extremes to 18 in the middle or neutral category) conforms to a normal distribution, requiring judges to make multiple evaluations among items and thereby avoid either negative or positive halo effects, and attenuating the influence of response sets (Block, 1961/1978). The interrater reliability for the Psychotherapy Process Q-set has been consistently satisfactory across a variety of studies and treatment samples, with Pearson product-moment correlations rangTable 1 Archival Data Sets Sample characteristic No. of patients Gender and ethnicity Age Diagnosis Exclusion criteria Inclusion criteria Therapists and training Average no. of sessions Outcome measures Treatment outcome effect size Clinically significant change3

Cognitive-behavioral therapy sample 16 in C/B therapy alone, and 16 in C/B therapy plus drug 26 F, 6 M; 88% White M = 33.8 years; range, 18-62 Depressive disorder Diagnosis of schizophrenia, organic impairment, mental deficiency, alcoholism, suicide risk BDI score > 20 H RSD-17 score > 14 1 psychologist, 3 social workers; special training & supervision in cognitive therapy 14.4 BDI, HRSD-17, ATQ, RDS, MMPI-D .66 on composite measure BDI: 0, 25; HRSD-17: 8, 31; RDS: MMPI-:0, 10; ATQ: 4, 25

Psychodynamic therapy sample

30

20 F, 10 M; 100% White M = 50 years; range, 20-81 Range of "neurotic disorders" Approximately the same History of meaningful interpersonal relationships; could benefit from brief psychotherapy 6 psychologists, 1 social worker, 8 psychiatrists; some training in brief therapy 15.8 SCL-90-R, BPRS .77 on GSI of SCL-90-R, .59 on BPRS SCL-90-R: 5, 18b

Note. C/B = cognitive-behavioral; F = female; M = male; BDI = Beck Depression Inventory; HRSD-17 = Hamilton Rating Scale for Depression; ATQ = Automatic Thoughts Questionnaire; RDS = Raskin Depression Scale; MMPI-Z) = Minnesota Multiphasic Personality Inventory Depression scale; SCL-90-R = Symptom Distress Checklist-Revised; GSI = General Severity Index; BPRS = Brief Psychiatric Rating Scale. a Number of subjects in the functional range (Jacobson & Truax, 1991) on each outcome index at pretreatment and at posttreatment. b Change rating, 86% improved.

COMPARING THERAPY PROCESSES judges who were blind to reliability checks; when agreement was below .50, a third rater was added. The first hour was selected to identify initial aspects of the therapy process, such as the formation of a therapeutic alliance, that might be predictive of outcome. The fifth hour was chosen to replicate the design of two previous studies (Jones, Cumming, & Horowitz, 1988; Jones, Krupnick, & Kerig, 1987). The 14th hour was selected to capture the end phase of treatment at a point where the hour would not be dominated by termination issues; an additional practical consideration was that some patients did not complete the full 16 sessions. Interrater reliability was calculated by using the Pearson product-moment correlation coefficient.

309

two samples were combined for all subsequent analyses (n = 32). Estimates of clinically significant patient change on several outcome indices are presented in Table 1. A large percentage of patients demonstrated reliable, clinically significant change on all outcome measures except the MMPI-D (only 10 of 32). Q-Descriptors of the Therapy Process The analysis of the process data was conducted in two stages, beginning with identifying the most and least characteristic Q-items for each treatment modality. This was followed by an analysis of differences in the therapy process in cognitive and psychodynamic treatments. Average interrater reliability for Qsorts of therapy sessions for both treatments (N= 186) achieved an r = .84. To identify the process descriptors that most strongly characterized each treatment, 100 item means were calculated from the individual Q-item placements at Hours 1, 5, and 14. The Q-items were rank-ordered, and the 10 most and least characteristic Q-items were identified. These Q-item means ranged from a high of 7.96 to a low of 1.54 (see Tables 2 and 3) on the 9-point Q-distribution. A strategy of organizing items according to meaning was chosen over a statistical or directional ordering of items so that the results might lend themselves more readily to clinical interpretation. The Q-item numbers mentioned later refer to the items in Tables 1-5; the word reversed (T) indicates that the variable required reflection to be oriented comparably in the narrative. Psychodynamic therapy: Most and least characteristic Qitems. In general, these brief treatments were characterized by an emphasis on patients' current life situation (Q-set Item 69; Q 69); however, patients' feelings and perceptions were also linked to past situations and behavior (Q 92). These patients as a group were sad and depressed (Q 94). Still, they tended not to have difficulty beginning the hour (Q 25), and they were not passive in initiating topics (Q 15, r); these findings are consistent with the fact that few silences occurred during the sessions (Q 12, r). The content in these hours consisted of significant issues brought up by the patient (Q 88), including interpersonal relationships (Q 63) and discussions of self-image (Q 35). The therapists in these treatments were characteristically accepting and nonjudgmental (Q 18). They emphasized patients' feelings (Q 81), clarified comments (Q 65), and identified recurrent themes in patients' experiences (Q 62). Therapists' interventions were not generally designed to shore up or strengthen patients' defenses or to suppress troublesome thoughts and feelings (Q 89, r). Patients readily understood (Q 5, r) and accepted (Q 42, r) therapists' comments, possibly because interventions were not tactless (Q 77, r) or condescending (Q 51, r). Overall, therapists were characterized by judges as responsive and affectively involved rather than distant and aloof in manner (Q 9), and patients appeared to feel understood (Q 14, r; see Jones et al., 1992, for a more complete discussion). Cognitive-behavioral therapy: Most and least characteristic Qitems. First, Q-sorts for the 16 patients who had been treated with cognitive-behavioral therapy and antidepressant medication were compared with those of the 16 patients who had been treated with cognitive-behavioral therapy alone. Fewer items distinguished these two groups than would be expected by chance (n = 94 items at p > .05). Correlations of Q-ratings for the two treatment conditions also demonstrated a high degree

Results The results are presented in the following sequence: first, data on treatment effectiveness in the two treatment groups are discussed separately; outcome between the two groups could not be compared directly because the data sets had no outcome measures in common, as well as for other design reasons. This is followed by an analysis of the Q data comparing the therapy process in the two treatment groups. Finally, the association between process and outcome is examined. Treatment Outcome: Effect Size and Clinical Significance Patient change in psychodynamic therapies. Assessments from patients, therapists, and independent clinical evaluators on the OCR showed an average rate of patient improvement from pre- to posttherapy of 86% (alpha = .71): change ratings were 83%, 97%, and 78% from patients, therapists, and evaluators, respectively. The standardized mean difference effect size coefficient (or d) was calculated for the SCL-90-R and BPRS scores pre- and posttreatment. Effect sizes were moderate: d = .77 for the SCL-90-R's General Severity Index (or GSI, which reflects average intensity of symptoms endorsed) and .59 for the BPRS total scores. Clinical significance of patient change was defined as in Jacobson and Truax's (1991) study: A patient achieves a posttest score on an outcome measure that is more likely to belong in the functional than the dysfunctional population. Cutoff scores were calculated using the means and standard deviations derived from normative data for functional and dysfunctional samples; it could then be determined whether a patient crossed this cutoff point in the direction of the normative functional sample from pretest to posttest. Estimates of clinically significant patient change, presented in Table 1, were for the most part reliable. These outcome data are reported more fully elsewhere (Jones, Parke, & Pulos, 1992). Patient change in cognitive-behavioral therapies. Outcome data for the cognitive-behavioral therapy sample are reported in detail by Hollon et al. (1989). Our analysis of these data corroborated the results reported there, demonstrating no significant differences in outcome between patients treated with cognitive-behavioral therapy alone and those treated with cognitive-behavioral therapy plus antidepressants on the various outcome measures (all ps > .05). Effect sizes (d) on a composite measure of the four outcome scales (BDI, HRSD, RDS, and MMPI-D) were moderate and comparable in size: d = .66 for cognitive-behavioral therapy plus antidepressant medication and .58 for cognitive-behavioral therapy alone (Hollon et al., 1989). In the absence of important differences in outcome, the

310

ENRICO E. JONES AND STEVEN M. PULOS Table 2 Rank Ordering ofQ-Items for Patients in Psychodynamic Therapy PQS item and no. 10 Least characteristic items Q 15. Q 25. Q 9. Q 14. Q 5. Q 89. Q 12. Q 51. Q 77. Q 42. P does not initiate topics; is passive. P has difficulty beginning the hour. T is distant, aloof. P does not feel understood by T. P has difficulty understanding T's comments. T acts to strengthen defenses. Silences occur during the hour. T condescends to or patronizes P. T is tactless. P rejects T's comments and observations. 10 Most characteristic items Q 69. Q 63. Q 62. Q 65. Q 88. Q 35. Q 92. Q 81. Q 94. Q 18. P's current or recent life situation is emphasized. P's interpersonal relationships are a major theme. T identifies a recurrent theme in P's experience or conduct. T clarifies, restates, or rephrases P's communication. P brings up significant issues and material. Self-image is a focus of discussion. P's feelings and perceptions are linked to the past. T emphasizes P's feelings in order to help him/her experience them more deeply. P feels sad or depressed. T conveys a sense of nonjudgmental acceptance. 7.60 7.16 6.98 6.91 6.87 6.81 6.75 6.57 6.41 6.40
1.88 2.09 2.42 2.43 2.46 2.59 2.65 2.65 2.69 2.70
M

Note. Average item means (Hours 1,5, and 14). The number of treatment hours = 90. PQS= Psychotherapy Process Q-set; T = therapist; P = patient.

of similarity, with correlations of .96 for Hour 1,.95 for Hour 5, and .92 for Hour 14. Q-data for cognitive-behavioral therapy alone as well as with antidepressant medication were subsequently combined for all further analyses. In cognitive-behavioral therapy, there was much discussion of ideational themes, beliefs, or constructs used to appraise the self, others, or the world (Q 30); patients' attitudes or perceptions of self were a concomitant focus (Q 35). Current and recent life situations (rather than the past) were emphasized (Q 69), and there was talk of activities or tasks the patient might attempt outside of the treatment session (Q 38). Patients appeared to readily comprehend what therapists said to them (Q 5, r), conveyed that they felt understood (Q 14, r), and had little difficulty beginning treatment hours (Q 25, r). They were described as very accepting of therapists' comments and observations (Q 42, r), compliant and deferential (Q 20, r), undemanding (Q 83, r), and collaborative (Q 87, r). This stance may have been in response to the active control (Q 17, 31) therapists assumed, although it may be explained in part by the relatively high levels of depression in this sample. Therapists frequently restated or rephrased the patient's statements to clarify them (Q 65), and there were few silences during the hours (Q 12, r). They were described as responsive and affectively involved (Q 9, r) and didactic (Q 37), and they frequently explained some aspect of the therapy or instructed the patient about certain therapy techniques (e.g., to imagine a conversation with someone during the hour; Q 57). These therapists were not neutral; that is, they expressed opinions or took positions (Q 93, r), and they were strongly supportive, encouraging, and approving (Q 45). Among the 10 items identified as most characteristic and least characteristic for psychodynamic and cognitive-behav-

ioral therapies, respectively, there were 9 items in common (6 uncharacteristic and 3 characteristic), suggesting that there are important commonalities across these treatment modalities. Differences and similarities in the therapy process across treatments. Differences between the two treatment modalities emerged more sharply in direct comparisons of Q-sorts of therapy sessions. The Q-item ratings for the sample of psychodynamic (TV = 90) and cognitive-behavioral (N = 96) therapy sessions were compared by submitting each of the 100 Q-items to a t test (two-tailed). Process in the two treatment modalities was strikingly different, with 57 of 100 items significantly differentiating the two treatments, 44 at the p < .001 level of significance and 13 at p < .01 (p < .01 was selected to reduce experimentwise error; see Table 4). In the presentation of the results of this comparison, statements are made that a given Q-item is more or less characteristic of a treatment, when sometimes the Q-item is rated as generally characteristic (or uncharacteristic) for both treatments in the Q-continuum, and hence such statements are relative in nature. The following set of items are grouped according to general conceptual similarity. Inspection of Table 4 will reveal additional items that supplement this summary characterization. As might be expected, there were many differences in therapist technique. It was more characteristic for psychodynamic therapists to encourage or facilitate patient speech (Q 3), identify recurrent patterns in patients' experience or behavior (Q 62), point out the use of defensive maneuvers used by the patient to ward off threatening information or feelings (Q 36), draw attention to thoughts or feelings regarded by the patient as unacceptable (Q 50) or not clearly in awareness (Q 67), and generally promote the experience of affect (Q 81). In contrast.

COMPARING THERAPY PROCESSES Table 3 Rank Ordering ofQ-Items for Patients in Cognitive-Behavioral Therapy PQS item and no. 10 Least characteristic items Q 9. T is distant and aloof. Q 5. P has difficulty understanding the T's comments. Q93. T is neutral. Q 42. P rejects T's comments and observations. Q 20. P is provocative, tests limits of therapy relationship. Q 14. P does not feel understood by T. Q 25. P has difficulty beginning the hour. Q 83. P is demanding. Q 87. P is controlling. Q 12. Silence occurs during the hour. 10 Most characteristic items Q 17. T actively exerts control over the interaction. Q 37. T behaves in a teacher-like (didactic) manner. Q 30. Discussion centers on cognitive themes. Q 69. P's current or recent life situation is emphasized. Q 38. There is discussion of specific activities or tasks for the P to attempt outside of session. Q 31. T asks for more information or elaboration. Q 35. Self-image is a focus of discussion. Q 57. T explains rationale behind his or her technique. Q 45. T adopts supportive stance. Q 65. T clarifies, restates, or rephrases P's communication. 7.96 7.82 7.78 7.50 7.46 7.43 6.95 6.94 6.91 6.80
1.54 2.42 2.56 2.63 2.81 3.88 2.97 3.01 3.02 3.08

311

Note. Average item means (Hours 1,5, and 14). The number of treatment hours = 96. PQS = Psychotherapy Process Q-set; T = therapist; P = patient.

cognitive-behavioral therapists more frequently provided direct advice and guidance (Q 27), suggested specific activities (Q 38) and, in an effort to help patients with interpersonal difficulties, attempted to explain the meaning of the behavior of other people in the patient's life (Q 43) and encouraged new or different ways of behaving with them (Q 85). Therapy sessions tended to have a more specific focus (Q 23), and greater attention was given to cognitive beliefs (Q 30). Unlike psychodynamic therapists, cognitive-behavioral therapists more usually acted to avoid or suppress patients' disturbing feelings and ideas (Q 89). Therapist stance, and the ensuing quality of the dyadic interaction, was also strikingly different across treatment modalities. Psychodynamic therapists were more distant or formal (Q 9; although therapists in both modalities were generally described as uncharacteristic in this regard) as well as more neutral (Q 93). They were judged to be more empathic (Q 6) and more likely to correctly perceive their patients' emotional state and the nature of the interaction (Q 28). Cognitive therapists were more actively controlling (Q 17) and didactic (Q 37); they were also much more approving and encouraging (Q 45) and reassuring (Q 66). However, these therapists were also judged by our raters to be more tactless (Q 77) and more condescending or patronizing (Q 51) (again, these Q-item means were in the uncharacteristic range for both treatments). In addition, their own emotional reactions more often intruded into the treatment in an unhelpful way (Q 24). However, when disagreement or conflict arose, cognitive-behavioral therapists were more accommodating or appeasing (Q 47). Psychodynamic therapies, relative to cognitive-behavioral treatments, were clearly more evocative of patient emotional

experience. Patients in dynamic therapies more often expressed angry or aggressive feelings (Q 84) or struggled to control strong emotions (Q 70); they also tended to be less compliant and more demanding (Q 83) and controlling (Q 87), and they experienced more ambivalent (Q 49), critical, or antagonistic (Q 1) feelings toward their therapists. In this context of heightened patient emotional states and patients' affective reactions to the therapist, the therapy relationship was a more important focus of discussion (Q 98). Therapists more frequently interpreted the transference (Q 100) and reformulated patients' in-therapy behavior in such a way as to give it a new or different meaning (Q 82). Patients in dynamic treatments were judged as achieving more self-understanding or insight than those in cognitive-behavioral therapies (Q 32). Thirty-eight Q-items did not significantly distinguish psychodynamic and cognitive-behavioral therapy processes, and of these, 26 were descriptors of patient attitudes or emotional states. In other words, what was not different concerned primarily the patients, not the treatments. There were no differences, for example, in patient levels of anxiety or guilt, feelings of inadequacy or inferiority, and depression or sadness (which was very characteristic of both patient samples). Patients' sense of trust, ability to understand their therapists, and sense of feeling understood was comparable in both treatments. They were rated as equivalent in their concerns about becoming dependent and their wish to rely on therapists to solve their problems. In both treatments, patients were equally committed to the work of therapy and similar in their levels of positive expectations about the treatment and the sense of feeling helped. It is likely that these kinds of patient attitudes and concerns are common in all modes of treatment.

312

ENRICO E. JONES AND STEVEN M. PULOS Table 4 Differences Between Q-Item Means for Psychodynamic and Cognitive-Behavioral Therapies PQS item and no. Psychodynamic treatment Cognitive-behavioral treatment

More characteristic of psychodynamic treatment 3. T's remarks are aimed at facilitating P's speech. 6. T is sensitive to P's feelings, attuned to P; empathic. 9. T is distant, aloof (vs. responsive and affectionately involved). 22. T focuses on P's feelings of guilt. 28. T accurately perceives the therapeutic process. 29. P talks of wanting to be separate or distant. 32. P achieves a new understanding or insight. 36. T points out P's use of defensive maneuvers (e.g., undoing, denial). 40. T makes interpretations referring to actual people in P's life (vs. makes general or impersonal interpretations). 50. T draws attention to feelings regarded by P as unacceptable (e.g., anger, envy, or excitement). 62. T identifies a recurrent theme in P's experience or conduct. 67. T interprets warded-offor unconscious wishes, feelings, or ideas. 72. P understands the nature of therapy and what is expected. 81. T emphasizes P's feelings to help him/her experience them more deeply. 82. P's behavior during the hour is reformulated by T in a way not explicitly recognized previously. 83. P is demanding. 84. P expresses angry or aggressive feelings. 9 1 . Memories or reconstructions of infancy and childhood are topics of discussion. 92. P's feelings or perceptions are linked to situations or behavior of the past. 93. T is neutral. 100. T draws connections between the therapeutic relationship and other relationships. 1 1 . Sexual feelings and experiences are discussed. 86. T is confident or self-assured (vs. uncertain or defensive). 87. P is controlling. 98. The therapy relationship is a focus of discussion. 41. P's aspirations or ambitions are topics of discussion. 46. T communicates with P in a clear, coherent style. 49. P experiences ambivalent or conflicted feelings about T. 70. P struggles to control feelings or impulses. 88. P brings up significant issues and material. 1. P verbalizes negative feelings (e.g., criticism, hostility) toward T (vs. making approving or admiring remarks). 6.2** 6.8** 2.4** 5.4** 6.6** 5.9** 5.6** 5.4** 6.3** 6.2** 7.0** 6.3** 5.6** 6.6** 5.3** 4.1** 6.1** 6.3** 6.8** 5.8**
5.1** 5.3**
4.8 5.9 1.5 4.4 5.6 4.9
4.7

3.6 5.0 4.4 5.7 4.2 4.6 3.2 4.5 3.0 4.8 4.5 4.9 2.6 4.0 4.5 5.8 3.0 4.6 5.2 5.5 4.3 4.0 6.3 3.7

6.4** 4.1** 5.3*

5.9* 5.9* 4.8* 4.5* 6.9* 4.2*

More characteristic of cognitive-behavioral treatment 15. P does not initiate topics; is passive. 1 7. T actively exerts control over the interaction (e.g., structuring, introducing new topics). 21. T self-discloses. 24. T's own emotional conflicts intrude into the relationship. 25. P has difficulty beginning the hour. 27. T gives explicit advice and guidance (vs. defers even when pressed to do so). 30. Discussion centers on cognitive themes (i.e., about ideas or belief systems). 37. T behaves in a teacher-like (didactic) manner.
1.9 4.9 3.5 3.0 2.1 3.9 5.0 3.9

3.4** 8.0** 5.4**

4.1** 3.0**

6.3** 7.8** 7.8**

COMPARING THERAPY PROCESSES

313

Table 4 (continued)
PQS item and no. Psychodynamic treatment Cognitive-behavioral treatment

More characteristic of cognitive-behavioral treatment (continued) 38. There is discussion of specific activities or tasks for P to attempt outside of session. 45. T adopts supportive stance. 5 1 . T condescends to, or patronizes P. 57. T explains rationale behind his/her technique or approach to treatment. 66. T is directly reassuring. 68. Real vs. fantasized meanings of experiences are actively differentiated. 74. Humor is used. 76. T suggests that P accept responsibility for his/her problems. 77. T is tactless. 79. T comments on changes in P's mood or affect. 80. T presents an experience or event in a different perspective. 85. T encourages P to try new ways of behaving with others. 89. T acts to strengthen defenses. 2. T draws attention to P's nonverbal behavior (e.g., posture, gestures). 23. Dialogue has a specific focus. 43. T suggests the meaning of others' behavior. 47. When the interaction with P is difficult, T accommodates in an effort to improve relations. 6 1 . P feels shy and embarrassed (vs. un-self-conscious and assured).
4.3 4.6 2.7 4.0 3.5 4.9 4.8 4.4 2.7
4.4

7.5** 6.9** 4.1** 6.9** 5.4** 6.3** 5.7** 5.2** 3.7** 5.1** 6.6** 5.8** 5.9**
4.6* 5.9* 5.3* 4.6* 4.6*

5.8 4.8 2.6 4.3 5.2 4.7 4.0 3.9

Note. Endpoints are extremely characteristic (9) and extremely uncharacteristic (1). Significant differences between Q-item means were obtained by two-tailed t tests; dfs = 1, 60. PQS = Psychotherapy Process Q-set; T = therapist; P = patient. * p < . 0 1 . **p<.001.

Process Factors: Their Correlation to Therapy Outcomes The comparison of Q-items across the treatment modalities demonstrates large and important differences. The question that then arose was whether there were underlying factors that the two treatments shared in common and, furthermore, whether any such dimensions might be associated with treatment effectiveness. The Q-ratings for all subjects at all three time points (N= 186 treatment hours) were subjected to a factor analysis (principal-components method). The factor analysis yielded four conceptually interpretable factors after varimax rotation, which together accounted for 42% of the variance in Q-sort descriptions. The items that best define the factors are listed in Table 5. Factor 1, Psychodynamic Technique, reflects therapists' actions and techniques usually associated with psychodynamic approaches. Factor 2, Cognitive-Behavioral Technique, captures therapists' activity from this theoretical perspective. Factor 3, Patient Resistance, reflects the extent to which a patient was or was not able to create a collaborative, working alliance with the therapist; felt committed to the treatment; and felt trusting, hopeful, understood, and helped. Factor 4, Negative Patient Affect, reflects the extent to which patients felt depressed and anxious or experienced other troublesome affect during therapy sessions. Factor scales were constructed by averaging the relevant PQS items for each of the four factors after

reversing the coding of items that were negative indicators of factors. The alpha reliabilities were .89, .93, .91, and .77 for Psychodynamic Technique, Cognitive-Behavioral Technique, Patient Resistance, and Negative Patient Affect, respectively. It seemed important to establish the validity of the labels selected to designate especially Factors 1 and 2. In Table 5, the 10 items that compose the factor Psychodynamic Technique are among the Q items that are rated as significantly more descriptive of the psychodynamic therapy sample (all ps < .001); similarly, the 10 items that compose the factor Cognitive-Behavioral Technique are among those that are more descriptive of the cognitive-behavioral therapy sample (all ps < .001). The fact that the factorially defined items are unique to, and totally encapsulated within, the items that distinguish the two therapy samples affirms the use of the psychodynamic technique and cognitive-behavioral technique designations and constitutes evidence that these factors are specific to the respective treatments. To determine whether the four process factors were associated with treatment outcomes, we calculated partial correlations (controlling for pretreatment) of outcome scores and patient scores on the factors. It was anticipated that high scores on Psychodynamic Technique would be associated with positive outcome in psychodynamic therapies and that high scores on Cognitive-Behavioral Technique would show a similar association with effectiveness in cognitive therapies. Surprisingly, this

314

ENRICO E. JONES AND STEVEN M. PULOS Table 5 Process Factor Items and Loadings PQS item and no. Factor 1: Psychodynamic Technique
81. 93. 67. 36. 92. 50.

Loading

91. 100. 82.

62.

T emphasizes P's feelings to help him/her experience them more deeply. T is neutral. T interprets warded-off or unconscious wishes, feelings, or ideas. T points out P's use of defensive maneuvers (e.g., undoing, denial). P's feelings or perceptions are linked to situations or behavior of the past. T draws attention to feelings regarded by P as unacceptable (e.g., anger, envy, or excitement). Memories or reconstructions of infancy and childhood are topics of discussion. T draws connection between the therapeutic relationship and other relationships. P's behavior during the hour is reformulated by T in a way not explicitly recognized previously. T identifies a recurrent theme in P's experience or conduct. Factor 2: Cognitive-Behavioral Technique

.81 .80 .70 .62 .61 .58 .57 .50 .50 .50

37 T behaves in a teacher-like (didactic) manner. 38 There is discussion of specific activities or tasks for P to attempt outside of

30

57. 27. 17. 51. 21. 66.

session. T acts to strengthen defenses. Discussion centers on cognitive themes (i.e., about ideas or belief systems). T explains rationale behind his/her technique or approach to treatment. T gives explicit advice and guidance (vs. defers even when pressed to do so). T actively exerts control over the interaction (e.g., structuring, and/or introducing new topics). T condescends to, or patronizes P. T self-discloses. T is directly reassuring. Factor 3: Patient Resistance

.76 .76 .74 .73 .73 .72 .67 .60

42. 14. 49. 44. 58. 1. 20. 39. 73. 95. 97. 55.

P rejects (vs. accepts) T's comments and observations. P does not feel understood by T. P experiences ambivalent or conflicted feelings about T. P feels wary or suspicious (vs. trusting and secure). P resists examining thoughts, reactions or motivations related to problems. P verbalizes negative feelings (e.g., criticism, hostility) toward T (vs. makes approving or admiring remarks). P is provocative, tests limits of the therapy relationship (vs. behaving in a compliant manner). There is a competitive quality to the relationship. P is committed to the work of therapy. P feels helped. P is introspective, readily explores inner thoughts, and feelings. P conveys positive expectations about therapy. Factor 4: Patient Negative Affect

.79 .73 .71 .70 .69 .66 .61 .57 -.72 -.74 -.62 -.61

94. 59. 26. 71. 7. Note.

P feels sad or depressed (vs. joyous or cheerful). P feels inadequate and inferior (vs. effective and superior). P experiences discomforting or painful affect. P is self-accusatory; expresses shame or guilt. P is anxious or tense (vs. calm and relaxed). PQS = Psychotherapy Process Q-set; T = therapist; P = patient.

.70 .67 .60 .59 .56

was not the case. Psychodynamic Technique was significantly correlated with patient improvement on four of five outcome scales for the cognitive-behavioral treatment sample, and Cognitive-Behavioral Technique showed little or no association with outcome (see Table 6). The correlation for Psychodynamic Technique to outcome in psychodynamic therapies showed a near-significant trend, whereas Cognitive-Behavioral Technique showed a significant negative association on one of four outcome scales in this treatment sample. Factor 3, Patient Resis-

tance, was significantly negatively correlated with outcome in both treatment samples (five of five outcome scales in cognitive-behavioral treatments and two of four scales in psychodynamic therapies). Factor 4, Patient Negative Affect, was negatively correlated with outcome in cognitive-behavioral therapies on the MMPI-.D, conversely, it was positively associated with outcome on one of four scales (therapist-rated BPRS) in psychodynamic treatments. This discrepancy may reflect the tendency, already captured in the analysis of individual Q-

COMPARING THERAPY PROCESSES

315

Table 6 Process Correlates of Outcome

Psychodynamic therapy Cognitive-behavioral therapy Process factor
BDI

ATQ -.31** .01 .30** .18

HRSD-17 -.33** -.02 .39*** -.09

MMPl-D -.47*** .09 .29* .38**

RDS -.39*** .08 .33** .19

OCR
-.30* .07 .34* -.05

BPRS (therapist)
-.19 .04 .65**** -.44**

BPRS (evaluator)
-.20 .35** .17 -.08

SCL-90-R
-.04 .04 .07 .04

1. Psychodynamic technique 2. Cognitive-behavioral technique 3. Patient resistance 4. Patient negative affect

-.18 -.06 .35** -.01

Note. A negative correlation reflects a positive association with outcome. All correlations are partial correlations controlling for patient pretreatment scores, except for overall change rating (OCR), which is a Pearson correlation. BDI = Beck Depression Inventory; ATQ = Automatic Thoughts Questionnaire; HRSD-17 = Hamilton Rating Scale for Depression; MMPI-.D = Minnesota Multiphasic Personality Inventory Depression scale; RDS = Raskin Depression Scale; BPRS = Brief Psychiatric Rating Scale; SCL-90-R = Symptom Distress ChecklistRevised. *p<AO. **p<.05. ***p<.01. ****/><.001.

items, for cognitive-behavioral therapies to emphasize the suppression and control of negative affect, whereas psychodynamic treatments focus on the exploration and expression of such feelings. Also, the cognitive-behavioral treatment sample comprised depressed patients, and this difference may reflect a relationship between more serious kinds of depression (Factor 4) and poorer outcome in that patient sample.

Discussion
The treatments in both the samples of psychodynamic and cognitive therapy studied here were as effective as generally reported by outcome studies (Smith et al., 1980). The question central to the present study, however, was to what extent the process data are useful for verifying or falsifying the clinical theoretical constructs from which these two treatment approaches derive. We think that here, our efforts have been fruitful. The therapy processes in the psychodynamic and cognitive treatments were strikingly different. Technique and emphasis in psychodynamic treatments were consistent with this orientation's theoretical frame. There was a focus on the evocation of affect, bringing troublesome feelings into awareness, and integrating current difficulties with previous life experience, using the therapist-patient relationship as a change agent. Confirmations of the usefulness of the psychodynamic orientation have been difficult to obtain. The effectiveness of therapist techniques conventionally associated with the psychodynamic modelsuch as therapist neutrality, the interpretation of warded-off ideas and the identification of unacceptable feelings, the identification of repetitive conduct patterns, and the interpretation of the transferenceall serve to verify the important position that these aspects of intervention have long held (e.g., Greenson, 1967). It is true that the strength of the relationship of the psychodynamic process to effectiveness are modest; nevertheless, these associations are as strong as any typically reported and bring new information to the current unsatisfactory state of affairs in the process-outcome literature. Some cognitive-behavioral theorists (e.g., Beck, Rush, Shaw, & Emery, 1979) have hypothesized that cognitive-behavioral therapies promote patient change by modifying specific maladaptive thinking patterns, such as dysfunctional attitudes or depressive attributional biases. Others (e.g., Marziller, 1986),

however, have suggested that the principal effect for cognitivebehavioral therapy lies in helping patients achieve greater control of depressive thinking and in offering alternative coping strategies such as distraction, monitoring negative thinking, and increasing pleasurable and mastery activities rather than in modifying dysfunctional beliefs. The data here suggest that these treatments as actually conducted (at least in this sample) emphasize the cognitive control of negative affect through the use of intellect and rationality, combined with vigorous encouragement, support, and reassurance on the part of the therapist. The finding that the process did not alter in cognitive-behavioral therapy as a function of pharmacotherapy deserves some emphasis, because it has been hypothesized that antidepressant medication may play a mediating role in cognitive treatments by affecting patients' cognition through altering mood state and, hence, patients' responsiveness to therapy. Instead, these results appear to support what Hollon, DeRubeis, and Evans (1987) have termed a "causal specificity/consequential specificity" model in which cognitive therapy's efficacy is mediated by mechanisms not influenced by antidepressant medication. In other words, changes in symptoms occur as a result of both cognitive-behavioral therapy and pharmacotherapy, but changes in cognitive processes (at least as far as they are reflected in the Q-descriptions of cognitive-behavioral therapy process) seem not to be dependent on changes in depressive symptoms such as vegetative signs, slowed thinking, or flat affect often responsive to antidepressant medication. The cognitive-behavioral therapies studied here were conducted within Beck's framework (Beck et al., 1979). Mahoney (1988) has made the distinction between "rationalist" and "developmental" approaches to cognitive-behavioral therapy. According to this distinction, rationalists focus on current problems, designate explicit goals, and are oriented toward the control or elimination of negative affect and symptoms; intense affect is conceptualized as the expression of irrational and unrealistic beliefs. The therapy relationship is viewed as entailing the service/delivery of technical instruction and guidance; what is imparted is knowledge and information, along with skills in their use. In contrast, the therapy relationship in the developmental perspective is viewed as a unique, safe context within which relationships with the self and world can be explored. Developmental history is emphasized (e.g., Guidano, 1987), and affect is conceptualized as a form of knowing. Emotional expe-

316

ENRICO E. JONES AND STEVEN M. PULOS Hollon, S. D, DeRubeis, R. J., & Evans, M. D. (1987). Causal mediation of change in treatment for depression: Discriminating between nonspecificity and noncausality. Psychological Bulletin, 102, 139-149. Hollon, S. D, DeRubeis, R. }.. Evans, M. D, Wiemer, M. I, Garvey, M. I, Grove, W M., & Tuason, V B. (1989). Cognitive-therapy, pharmacotherapy and combined cognitive-pharmacotherapy in the treatment of depression. Manuscript submitted for publication. Hollon, S. D, & Kendall, P. G. (1980). Cognitive self-statements in depression: Development of an Automatic Thoughts Questionnaire. Cognitive Therapy and Research, 4, 383-395. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19. Jones, E. E. (1985). Manual for the psychotherapy process Q-set. Unpublished manuscript, University of California, Berkeley. Jones, E. E., Cumming, J. D, & Horowitz, M. J. (1988). Another look at the nonspecific hypothesis of therapeutic effectiveness. Journal of Consulting and Clinical Psychology, 56, 48-55. Jones, E. E., Hall, S., & Parke, L. A. (1991). The process of change: The Berkeley Psychotherapy Research Group. In L. Beutler & M. Crago (Eds.), Psychotherapy research: An international review of programmatic studies (pp. 98-107). Washington, DC: American Psychological Association. Jones, E. E., Krupnick, J. H., & Kerig, P. K. (1987). Some gender effects in a brief psychotherapy. Psychotherapy, 24, 336-352. Jones, E. E., Parke, L. A., & Pulos, S. (1992). How therapy is conducted in the private consulting room: A multivariate description of brief psychodynamic treatments. Psychotherapy Research. 2, 16-30. Luborsky, L., & DeRubeis, R. J. (1984). The use of psychotherapy treatment manuals: A small revolution in psychotherapy research style. Clinical Psychology Review, 4, 5-14. Mahoney, M.J. (1988). The cognitive sciences and psychotherapy: Patterns in a developing relationship. In R. Dobsin (Ed.), Handbook of cognitive behavioral therapies (pp. 357-386). New York: Guilford Press. Marziller, J. S. (1986). Changes in depressive beliefs: An analysis of Beck's cognitive therapy for depression. In Advances in cognitive-behavioral research and therapy (Vol. 5, pp. 89-114). San Diego, CA: Academic Press. Miller, R. C, & Berman, J. S. (1983). The efficacy of cognitive behavior therapies: A quantitative review of the research evidence. Psychological Bulletin, 94, 39-53. Overall, J., & Gorham, D. (1962). The Brief Psychiatric Rating Scale. Psychological Reports, 10, 799-812. Persons, J. B. (1991). Psychotherapy outcome studies do not accurately represent current models of psychotherapy: A proposed remedy. American Psychologist. 46, 99-106. Raskin, A., Schulterbrandt, J. G., Reatig, N., & McKeon, J. J. (1970). Differential response to chloropromazine, imipramine, and placebo. Archives of General Psychology, 23, 164-173. Smith, M. S., Glass, G. V, & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. Spitzer, R. L., Endicott, J., & Robins, E. (1979). Research Diagnostic Criteria (RDC) for a selected group of functional disorders (3rd ed.). New York: Biometric Research, New York State Psychiatric Institute. Stiles, W B., Shapiro, D. A., & Elliott, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165-180. Received February 11,1992 Revision received May 4,1992 Accepted May 4, 1992

rience is encouraged, and insight is viewed as a higher order level of knowing that is metacognitive in nature. Many elements of a developmental approach to cognitivebehavioral therapy are contained in the process factor which is here designated as Psychodynamic Technique. The extent to which these cognitive-behavioral therapies contained ingredients of psychodynamic technique was associated with positive outcome. In fact, this factor was most consistently associated with favorable treatment outcome in both psychodynamic and cognitive-behavioral therapies. The common core of therapeutic process across different approaches may well be located in this domain. Process research, more than comparative outcome studies or even experimental (extraclinical) tests, is likely to be useful in providing evidence for or against the theoretical propositions that guide psychologically mediated interventions. After all, theories of psychotherapy ultimately derive from observations about clinical phenomena and change processes. The challenge lies in developing methodologies that begin to capture effectively the complexities of the therapy process, particularly those that are applicable across theoretical schools with their different clinical constructs and diverse descriptive language. This comparative study of the therapy process represents a step in that direction.

References
Beck, A. T., Rush, A. J., Shaw, B. F, & Emery, G. (1979). Cognitive theory of depression. New York: 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. Block, J. (1978). The Q-sort method in personality assessment and psychiatric research. Springfield, IL: Charles C Thomas. (Original work published 1961). Derogatis, L. R., Lipman, R. S., Rickets, K.., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19,1-15. DeRubeis, R., Hollon, S. D., Evans, M. D., & Bemis, K. M. (1982). Can psychotherapies for depression be discriminated? A systematic investigation of cognitive therapy and interpersonal therapy. Journal of Consulting and Clinical Psychology, 50, 744-756. Elkin, L, Shea, T., Watkins, J., Imber, S., Sotsky, S., Collins, J., Glass, D., Pilkonis, P., Leber, W, Docherty, J., Fiester, S., & Parloff, M. (1989). National Institute of Mental Health treatment of depression. Collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-982. Frieswyck, S. H.. Allen, J. G., Colson, D. B., Coyne, L., Gabbard, G. Q, Horwitz, L., & Newsom, G. (1986). Therapeutic alliance: Its place as a process and outcome variable in dynamic psychotherapy research. Journal of Consulting and Clinical Psychology, 54, 32-38. Greenson, R. R. (1967). The technique and practice of psychoanalysts. New York: International University Press. Guidano, V F. (1987). Complexity of the self New York: Guilford Press. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology, 6, 278-296. Hathaway, S. R., & McKinley, J. C. (1983). Minnesota Multiphasic Personality Inventory: Manual for administration and scoring. Minneapolis: University of Minnesota Press.