Psychotherapy 2015, Vol. 52, No. 1, 38 – 44

© 2015 American Psychological Association 0033-3204/15/$12.00

Psychotherapy: Process, Mechanisms, and Science–Practice Integration James F. Boswell

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University at Albany, State University of New York I received the Early Career Award from Division 29 and the American Psychological Foundation in 2013. In this article, I briefly review some of my research areas, relevant issues, and future directions. Specifically, I focus on 3 core research areas: psychotherapy process– outcome, psychotherapy integration, and science–practice integration. Within each of these core areas, I also touch on important methodological issues. In addition, I argue that progress in the field will require the application of diverse research methods, spanning basic and applied areas, as well as interdisciplinary and interinstitutional collaboration. Keywords: psychotherapy process– outcome, psychotherapy integration, science–practice integration

comes (e.g., Boswell, Sauer-Zavala, Gallagher, Delgado, & Barlow, 2012).

I was honored to receive the Early Career Award from the American Psychological Foundation and Division 29 of the American Psychological Association. This award has been especially meaningful because of the impact the Division of Psychotherapy (now the Society for the Advancement of Psychotherapy) has had on my professional identity (at the time of writing this article, it has been six years since I served as a representative on Division 29’s graduate student committee). Broadly, my work is focused on understanding how and for whom psychotherapy works (or does not work), as well as methods for improving the study and impact of psychological interventions. In this article, I briefly review some of my research areas, relevant issues, and future directions. In particular, I focus on psychotherapy process– outcome research, psychotherapy integration, and science–practice integration.

Process Variable Interactions Advanced statistical methods, such as multilevel modeling, can be incredibly useful for investigating multiple sources of variance and cross-level (e.g., clinician, patient, session) interactions in psychotherapy. My colleagues and I (Boswell, Castonguay, & Wasserman, 2010) used multilevel modeling to examine the relationships among psychotherapy training, diverse model intervention use, participant factors, and session outcome in a universitybased community mental health center. Despite receiving targeted training and supervision in specific theoretical models, traineetherapists reported using a range of common and theory-specific interventions. Significant variability was observed in patient-rated session outcome and therapist-rated intervention use at all levels of analysis— between therapists, within therapists (between patients), and between sessions (session-to-session within patients). When examined at the session level (aggregated across patients and therapists), sessions that involved greater use of interpersonal therapy interventions and common factor strategies (e.g., enhancing the working relationship, instilling hope and positive expectancies) were rated as more helpful and positively impactful by patients. However, a significant three-way interaction was also found between common factor strategies and the use of cognitive– behavioral therapy (CBT) interventions. Patients of “high common factor” therapists (i.e., therapists who reported focusing more on common factors than the average therapist in the sample), who were participating in treatments that focused more heavily on common factors than the average patient’s treatment in that therapist’s caseload, rated sessions with higher than average CBT intervention use significantly less helpful and less positively impactful. These results highlight the importance of examining common and unique intervention use at multiple levels. The use of CBT interventions per se was not problematic; rather, it was the increased use of CBT interventions on the part of historically nondirective therapists who were facilitating relatively nondirective treatments, potentially illustrating the negative effects of breaking

Psychotherapy Process–Outcome Psychotherapy process– outcome researchers typically focus on three broad categories of variables: participant factors, relationship factors, and technical factors (model-specific and common). Unfortunately, these categories are occasionally framed as being in opposition to one another, and it is common for studies to focus on a single category while ignoring the others (or treating them as nuisance variables). Despite this, most psychotherapists and psychotherapy researchers recognize that change is complex and multidetermined. Interventions are delivered in a relational context, as well as in the context of other interventions. Participant behavior is mutually responsive (Stiles, 2009; Stiles, Honos-Webb, & Surko, 1998), and associations between relationship variables and treatment outcome can vary as a function of participant characteristics (see Zack et al., in press). Consequently, my colleagues and I have devoted significant attention to the study of interactions between important process variables in explaining treatment out-

This article was published Online First January 19, 2015. Correspondence concerning this article should be addressed to James F. Boswell, Social Science 307, Department of Psychology, University at Albany, SUNY, 1400 Washington Avenue, Albany, NY 12222. E-mail: [email protected] 38

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an established treatment frame. This has important implications for psychotherapy integration (Boswell, Llera, Newman, & Castonguay, 2011; Boswell & Goldfried, 2010). Although technical flexibility is an important element of being responsive (see Owen & Hilsenroth, 2014), there are also dangers to haphazard integration. The aforementioned study involved naturalistic treatment with therapists in-training. In a more recent study (Boswell et al., 2013), we examined intervention use, participant factors, and treatment outcome in the context of a large randomized clinical trial (RCT) testing a manualized CBT treatment for principal panic disorder with or without agoraphobia (see Aaronson et al., 2008 and White et al., 2013). In this multisite trial, all participants received 11 sessions of CBT in the acute treatment phase. Randomly selected audiotaped sessions were rated for psychotherapist adherence and competence by independent trained assessors. Consistent with most RCTs, psychotherapists were highly trained, received ongoing supervision, and were required to demonstrate a criterion level of adherence and competence with training cases prior to accepting a study case. The majority of psychotherapists had a terminal PhD or MD, and most identified with a CBT orientation. Consistent with previous research conducted by Imel, Baer, Martino, Ball, and Carroll (2011), results from multilevel models demonstrated significant between- and within-therapist variability in adherence and competence. Significant decrements in both adherence and competence were observed over the course of treatment. Higher patient trait interpersonal aggression was associated with lower independent observer coder ratings of therapist adherence and competence. However, neither adherence nor competence was predictive of outcome when controlling for symptom severity measured prior to each coded session. Given the nature of the adherence/competence scale, we can only speculate as to what else the study therapists were doing in the sessions with lower fidelity ratings. Nevertheless, the observed fidelity “drift” and the negative impact of patient trait aggression indicate that training and implementation efforts should involve continued consultation over multiple cases, in order to account for relevant patient factors and promote sustained fidelity across sessions and patients. The study results described above highlight the complexity of the interactions that exist among key process variables and their relationships with both session-level and posttreatment outcomes. Work in psychotherapy integration represents a laudable attempt to address this complexity.

Psychotherapy Integration I have always been interested—philosophically, empirically, and clinically—in psychotherapy integration (Boswell, Sharpless et al., 2011). My thinking has been heavily influenced by my graduate mentor, Louis Castonguay, and my “academic grandfather,” Marvin Goldfried. As a clinician and clinical-researcher, I am particularly interested in the identification of change strategies and mechanisms that cut across different treatment models and diagnostic categories. As eloquently stated by Goldfried (1980) “To the extent that clinicians of varying orientations are able to arrive at a common set of strategies, it is likely that what emerges will consist of robust phenomena, as they have managed to survive the distortions imposed by the therapists’ varying theoretical biases” (p. 996). I believe the same logic applies to the application of transdiagnostic intervention strategies that target core, shared


mechanisms of pathology (Boswell, 2013). Along these lines, my research has focused on the role of emotion and emotion regulation across different treatment approaches and problem areas. With the exception of anxiety and fear in exposure-based treatments, CBT has, historically, focused more on controlling and containing negative emotion (Blagys & Hilsenroth, 2000; Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997; Jones & Pulos, 1993; Samoilov & Goldfried, 2000; Wiser & Goldfried, 1998). In contrast, experiential (Greenberg, Auzra, & Hermann, 2007; Watson & Benard, 2006) and psychodynamic (Blagys & Hilsenroth, 2000; Goldfried et al., 1997) psychotherapies have focused more on the expression and deepening of diverse emotions (Boswell, Sharpless et al., 2011). Decades of research has not only provided empirical support for therapist actions that facilitate patients’ expression of emotion (Coombs, Coleman, & Jones, 2002; Greenberg & Foerster, 1996) and emotional processing (Goldman, Greenberg, & Pos, 2005; Pos et al., 2003; Warwar & Greenberg, 1999), but positive relationships between these factors and outcome have been observed in CBT— even when not included explicitly in the treatment protocol (Ablon & Jones, 1998; Coombs et al., 2002; Watson & Benard, 2006). Several clinical-researchers have argued that emotion may represent a key pathway of psychotherapy integration (Greenberg & Korman, 1993; Samoilov & Goldfried, 2000). A common theme of more recently developed CBT-oriented treatments has been an increased focus on emotions (Mennin, Ellard, Fresco, & Gross, 2013). For example, researchers at Penn State University have attempted to augment the effectiveness of CBT for generalized anxiety disorder by integrating interpersonal and emotionalprocessing interventions (I/EP; Castonguay, Newman, Borkovec, Grosse Holtforth, & Maramba, 2005). In the context of an RCT that used an additive design to test this augmentation (Newman et al., 2011), my colleagues and I (Boswell, Castonguay, Newman & Borkovec, 2010) examined intensity of emotional arousal in three treatment segments: CBT, I/EP, and supportive listening (SL). A series of double-repeated multilevel ANOVA models were tested. Among the results, significantly higher levels of love, sadness, and anger were observed in the I/EP segments compared with the CBT segments, and no differences in emotional intensity were observed between CBT and the SL segment. In addition, patients who experienced higher levels of joy in I/EP and CBT rated those segments as more helpful and positively impactful; however, this relationship was not observed in the SL segment. Across the segments, sessions that involved higher levels of sadness were perceived more negatively by patients. Although speculative, increases in experienced sadness may have been a function of reductions in cognitive avoidance. Despite the potential long-term therapeutic benefit of this, patients might have subjectively experienced this as aversive in the moment or short-term. Furthermore, intense sadness may be more dysregulating in a treatment that is specifically geared toward anxious experience. This issue may be at least partly addressed by a transdiagnostic approach to emotion regulation. Accumulating research in emotion science (Etkin & Wager, 2007; Fellous & Ledoux, 2005; LeDoux, 1996) and psychopathology (Brown, 2007; Campbell-Sills, Barlow, Brown, & Hofmann, 2006) points to common, underlying etiological and maintaining factors across the spectrum of problem areas that involve a prominent emotion component (e.g., mood, anxiety, eating, and somatic

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symptom disorders). These factors include core dimensions of temperament, specifically, neuroticism, characterized by an enduring tendency to experience negative affect (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014), which is typically accompanied by sensitivity or negative reactivity to affective experience (SauerZavala et al., 2012). Transdiagnostic treatments, such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2011), have been developed to address these underlying factors. The UP is an emotion-focused CBT treatment that integrates common evidence-based CBT principles and strategies, as well as recent developments in basic and applied emotion science (Boswell, 2013). Our research group has conducted several process– outcome investigations of transdiagnostic emotion-regulation constructs in the context of UP treatment. In one study, we examined the relationship between change in negative reactivity to emotion and outcome in a mixed anxiety disorder UP treatment sample (SauerZavala et al., 2012). The UP does not focus directly on reducing negative emotion; in fact, a key principle is that attempts to avoid, control, and suppress emotion (positive or negative) maintain distress and maladaptive behaviors. Rather, the UP aims to reduce emotion avoidance, improve emotion tolerance, and promote more adaptive responses to strong emotions. Consequently, change in negative reactivity to emotion (via reductions in constructs such as fear of emotions) should be a stronger predictor of outcome than change in the frequency of negative emotion alone. Our results supported this hypothesis. Although reductions in both the frequency of negative emotions and reactivity to emotions were both large in magnitude over 18 sessions, change in reactivity remained a significant predictor of outcome when controlling for negative emotion and accounted for significant incremental outcome variance. Additional research has demonstrated the transdiagnostic relevance of other constructs that have implications for emotion regulation, such as intolerance of uncertainty (Boswell, ThompsonHollands, Farchione, & Barlow, 2013) and anxiety sensitivity (Boswell, Farchione et al., 2013). Research across a wide range of problem areas has documented abnormal levels of interoceptive sensitivity (Otto, 2008). This sensitivity to internal experience (including the somatic components of emotions) appears to represent not only a cognitive vulnerability for pathology but potentially promotes maladaptive interoceptive conditioning (Bouton, Mineka, & Barlow, 2001). This and other forms of intolerance are associated with maladaptive emotion regulation strategies, which maintain and strengthen negative affect and subsequent avoidance (Brown & Barlow, 2009; Campbell-Sills et al., 2006). Interoceptive exposure (IE) is a potent intervention strategy originally developed to treat panic disorder (Barlow, Craske, Cerny, & Klosko, 1989) that aims to extinguish problematic associations and related distress. My colleagues and I (Boswell et al., 2013) studied IE and anxiety sensitivity as an indicator of emotion intolerance (or generalized interoceptive sensitivity) in an RCT examining the efficacy of the UP for diverse principal anxiety disorders and comorbid conditions (Farchione et al., 2012). Significant decreases in anxiety sensitivity were observed across all principal diagnoses, as well as similar change trajectories. Reductions in anxiety sensitivity were associated with lower clinical severity at posttreatment, and the largest reductions in anxiety sensitivity were observed

after the introduction of an IE intervention module. In addition, the IE procedures (in terms of both content and process) were found to be applied similarly across primary problem areas. We are beginning to study the integration and implementation of IE in eating disorder treatment (Boswell, Anderson, & Anderson, in press). Similar to other problem areas, deficits in interoceptive awareness and abnormalities in interoceptive sensitivity are both associated with diverse eating pathology. Relevant physical cues and sensations span both eating/digestion-related experience (e.g., appetite, satiety) and basic emotions (e.g., autonomic arousal experienced as part of anxiety); in fact, these cues likely become associated such that digestion physiology triggers anxiety (arousal and anxious cognitions regarding weight gain and discomfort), which in turn drives restriction or compensatory behaviors (which can be negatively reinforcing; Zucker et al., 2013). We believe that the relevance of IE as an intervention strategy can and should be expanded. Consistent with contemporary views on enhancing inhibitory learning (Craske et al., 2008), IE involves asking the patient to notice, label, and fully experience (in the absence of avoidance) uncomfortable internal sensations and associated emotion states. Although theoretical and technical differences can be identified, the strategic elements of IE are strikingly similar to Gendlin’s (1996) focusing method to promote immediate affective awareness and experiencing, from an experiential tradition. Similar to what Goldfried (1980) has argued, CBT and experiential approaches are working from distinct theoretical models, yet there may be considerable convergence when it comes to the principles that account for change (Boswell, 2013). This supposition can be tested directly through change mechanism research (Kazdin, 2007).

Mechanisms of Change Although changes in emotion reactivity, uncertainty intolerance, neuroticism (Carl, Gallagher, Sauer-Zavala, Bentley, & Barlow, 2014), and anxiety sensitivity during UP treatment have been linked to improvements in symptoms and functioning, rigorous tests of hypothesized change mechanisms are still needed. As cogently described by Kraemer and colleagues (Kraemer, Wilson, Fairburn, & Agras, 2002; Kraemer, Kiernan, Essex, & Kupfer, 2008), study designs and statistical methods must meet specific criteria in order to properly test putative mediators and moderators. Method discussions in this area focus almost exclusively on between-subjects designs, and with good reason given that RCTs represent the gold standard for evaluating comparative treatment efficacy. However, alternative methods for identifying and testing hypothesized mechanisms exist, and may even be preferable depending on the particular question or stage of the research (Barlow & Nock, 2009). For example, idiographic and person-specific research methods allow for the examination of temporal causal patterns and functional relationships between variables of interest (Barlow, Nock, & Hersen, 2009; Molenaar & Newell, 2010). Person-specific and single case designs are well-suited for testing mechanisms of change at both the therapist intervention and within-patient levels (which are often confused or conflated). For example, the finding that symptoms decrease in CBT through reductions in anxiety sensitivity (anxiety sensitivity is a mediator) demonstrates a within-patient mechanism. If this study used an RCT design, then

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we might reasonably conclude that change in anxiety sensitivity is attributable to CBT (vs. a comparison condition). However, in a multicomponent treatment, we still know very little about the precise intervention mechanisms responsible for change in anxiety sensitivity and, thereby, symptom reduction. The common approach of examining intervention mechanisms by correlating overall fidelity ratings with distal treatment outcomes is similarly uninformative (Webb, DeRubeis, & Barber, 2010). Alternative research designs allow for the examination of proximal intervention impacts on putative change mechanisms, as well as the relationships between identified change mechanisms and outcome. We used an alternative, idiographic approach to examine processes of change in a UP treatment case (Boswell, Anderson, & Barlow, 2014). This older adult patient was seeking treatment for depression and anxiety. Treatment followed the published UP manual (Barlow et al., 2011), and the patient completed repeated assessments of symptoms, mindfulness, cognitive reappraisal, and emotion avoidance over 22 sessions of individual psychotherapy. Univariate and multivariate time series models were used to examine the dynamic relationships between these factors. Results showed that increases in mindfulness reliably preceded reductions in depressive and anxious symptoms, and increases in reappraisal capacity reliably preceded reductions in depressive symptoms. Interrupted time series models indicated that the introduction of UP present-focused, nonjudgmental awareness strategies had the largest impact on the mindfulness time series (compared with the introduction of other treatment strategies). Interestingly, the early introduction of emotion monitoring and functional assessment skills exerted the strongest impact on the reappraisal time series, compared with subsequent strategies, including formal cognitive reappraisal skills (although the introduction of cognitive reappraisal strategies did exert a moderate effect). Hypothetically, if we had used a traditional between-subjects design, it is possible that the overall correlation between UP adherence scores and termination outcome would have been small or nonsignificant, potentially leading to the conclusion that specific interventions are unimportant. Rather than represent clinical reality, this would be an artifact of the method, in my view. It is more interesting and relevant to establish immediate functional relationships between specific interventions or therapist behaviors, target psychological mechanisms, and key outcome variables. In line with this, my colleagues and I are conducting a study that uses alternating treatment and multiple baseline single case designs to experimentally test both intervention and patient-level UP mechanisms. Unfortunately, in the absence of additional work to address the science–practice gap in mental health treatment, our results may have a limited impact on clinical practice.

Science–Practice Integration Highlighted by the joint “two-way bridge” initiative of the Society of Clinical Psychology (Division 12) and the Society for the Advancement of Psychotherapy (Division 29) (Goldfried et al., 2014), our ability to reduce the burden of mental illness and the science–practice gap will depend on active communication and collaboration among researchers and clinicians. In addition to conducting research that is clinically relevant, it is crucial to identify effective methods for dissemination, implementation, and training (Boswell & Castonguay, 2007; Boswell, Nelson, Nord-


berg, McAleavey, & Castonguay, 2010), as well as the factors (patient, clinician, supervisor, and organization-level) that are disruptive to these endeavors (Boswell & McHugh, in press; De Jong et al., 2012). As one method of “practice-oriented research” (Castonguay, Barkham, Lutz, & McAleavey, 2013), I have been fortunate to participate in several practice-research networks (see Castonguay et al., 2010; Locke et al., 2011; Nordberg et al., 2014) that bring together clinicians and researchers in the design, conduct, and dissemination of ecologically valid research. A cornerstone of these projects has been routine outcome monitoring (ROM) and feedback (Boswell, McAleavey, Castonguay, Hayes, & Locke, 2012). Also known as measurement-based care (MBC), routine outcome monitoring and feedback involves the collection of routine progress and outcome data via standardized assessment tools, to inform treatment with this patient. Research has consistently demonstrated that MBC improves patient treatment outcomes and reduces the risk of deterioration (Lambert, 2010). MBC holds tremendous promise for enhancing treatment responsiveness and mental health care decision making (Constantino, Boswell, Bernecker, & Castonguay, 2013), regardless of one’s theoretical orientation or the patient’s presenting problem. Despite having reached the level of an ethical mandate (Kraus, Castonguay, Boswell, Nordberg, & Hayes, 2011), barriers to the implementation and use of ROM and feedback systems persist (Boswell, Kraus, Miller, & Lambert, 2013). Although many clinicians remain hesitant to adopt MBC practices, it is becoming increasingly common for organizations and external bodies (e.g., health insurers, state agencies, Centers for Medicare and Medicaid Services) to require routine outcome and “quality” data from patients and providers (Bremer et al., 2008; Institute of Medicine, 2007). Thus, the relevant question is no longer “if” the collection of behavioral health outcomes data will be standard practice and expanded to inform a variety of health care decisions. Rather, the relevant questions are “when” and “how” the use of such information will be expanded (Boswell, Constantino, & Kraus, 2014). My colleagues and I have engaged multiple mental health care stakeholders in an effort to collaboratively design and test mutually beneficial strategies for harnessing ROM-based decision making in routine clinical practice settings. We have found that patients, clinicians, and administrators value feedback and the use of strategies that can enhance patient centeredness and treatment responsiveness (Boswell et al., 2014).

Future Directions I continue to be motivated by the pursuit of understanding how and why people change, for better or for worse. The relevance of the research questions and implications for everyday clinical practice and training will continue to be of paramount importance. With the field’s increasing emphasis on the identification of treatment mechanisms, this is an exciting time to be a psychotherapy process researcher. As noted above, I also believe that (if we are honest with ourselves) the undercurrents of psychotherapy integration are increasing in strength. This is not coincidental but a direct result of prioritizing the identification of active change ingredients in multiple forms of psychotherapy and across problem areas. Our success in identifying and harnessing core mechanisms will require the application of a variety of research methods,


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spanning basic and applied areas, as well as interdisciplinary collaboration. For example, I am involved in ongoing collaborative efforts to (a) implement transdiagnostic treatment strategies and principles in a large network of eating disorder treatment facilities, and, as noted above, (b) harness ROM to inform mental health treatment decision making at multiple levels (e.g., health care organizations). Both of these efforts involve a large team of stakeholders, including patients, clinicians (of diverse backgrounds and disciplines such as psychology, psychiatry, nursing, nutrition, social welfare, and primary care), implementation scientists, clinic administrators, computer programmers, and private business. These projects cut across diagnostic and traditional theoretical boundaries. In addition, they involve the application of mixed methods— quantitative, qualitative, and community-based. Despite this systems-level focus, we have not forgotten the individual patient. Building on our recent single-case design studies (Boswell et al., 2014; (Brake et al., 2015), our research lab at the University at Albany is piloting the use of novel social sensing technology (Lazer et al., 2009) to explore intraindividual and dyadic processes in psychotherapy. With this technology, extremely large amounts of data on a variety of social and behavioral indicators can be gathered within a single psychotherapy session. This level of assessment of temporal dynamics would be impossible with traditional coding methods. In particular, we will be examining the within-individual (patient and clinician) and dyadic processes that optimize the implementation of exposure-based interventions. It will be fascinating to see if this technology can also be integrated into routine psychotherapy as a feedback and/or training resource.

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Received November 16, 2014 Accepted November 18, 2014 䡲

Psychotherapy: process, mechanisms, and science-practice integration.

I received the Early Career Award from Division 29 and the American Psychological Foundation in 2013. In this article, I briefly review some of my res...
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