The ability of several process variables to predict therapy outcome was tested with 30 depressed clients who received cognitive therapy with or without medication. Two types of process variables were studied: 1 variable that is unique to cognitive therapy and 2 variables that this approach is assumed to share with other forms of treatment. The client's improvement was found to be predicted by the 2 common factors measured: the therapeutic alliance and the client's emotional involvement (experiencing). The results also indicated, however, that a unique aspect of cognitive therapy (i.e., therapist's focus on the impact of distorted cognitions on depressive symptoms) correlated negatively with outcome at the end of treatment. Descriptive analyses that were conducted to understand this negative correlation suggest that therapists sometimes increased their adherence to cognitive rationales and techniques to correct problems in the therapeutic alliance. Such increased focus, however, seems to worsen alliance strains, thereby interfering with therapeutic change.Despite support for the effectiveness of cognitive therapy for depression, researchers are still confronted with a high degree of uncertainty about its underlying processes of change (Whisman, 1993). As recently noted by Beck and Haaga (1992), the refinement of our understanding of the mechanisms of action in the treatment of depression will take a predominant place in the future of cognitive therapy. The present study is an attempt to better understand the process of change in cognitive therapy for depression.As recommended by several workers in the field (e.g., Kazdin, 1986;Lambert, Shapiro, & Bergin, 1986), two types of processes were investigated: variables that are unique to cognitive

This article describes important findings that have emerged from decades of research on the working alliance, as well as some of the clinical implications of these findings. In addition, future directions of research on this construct are suggested. Our hope is that this article will provide useful heuristics for better understanding the alliance, the therapeutic relationship more broadly, and the process of therapeutic change in general. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of "effective" and "harmful" therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d= -0.91 to -1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.

The current state of college student mental health is frequently labeled a "crisis," as the demand for services and severity of symptomatology have appeared to increase in recent decades. Nationally representative findings are presented from the Center for Collegiate Mental Health, a practice research network based in the United States, composed of more than 340 university and college counseling centers, in an effort to illuminate trends in symptom severity and patterns in treatment utilization for the campus treatment seeking population. Clinical data collected over 5 academic years (2010-2015) showed small but significantly increasing trends for self-reported distress in generalized anxiety, depression, social anxiety, family distress, and academic distress, with the largest effect sizes observed for generalized anxiety, depression, and social anxiety. On the other hand, a significantly decreasing trend was observed for substance use. No significant changes were observed for eating concerns and hostility. Utilization data over 6 years indicated a gradual yet steady increase in the number of students seeking services (beyond the rate expected with increasing institutional enrollment), as well as increases in the number of appointments scheduled and attended, with great variation between centers. Within the context of changing national trends, we conclude that it is advisable to consider the specific needs of local centers to best accommodate distinct student bodies. (PsycINFO Database Record

The goal of this article is to delineate training implications regarding harmful effects associated with psychotherapy. The authors strongly recommend that trainees be made aware of (and encouraged to examine carefully) the potentially harmful treatments that have been recently identified (Lilienfeld, 2007). Consistent with a broad perspective on evidence-based practice, it is also argued that additional guidelines for the prevention and repair of harmful impacts can be derived from psychotherapy research on process (technique and relationship) and participant (client and therapist) variables. For example, rigid adherence to the application of psychotherapy techniques can be a potentially harmful therapist behavior that necessitates careful training on the nature and flexible use of interventions. Furthermore, the authors suggest that trainers and supervisors tentatively consider training implications linked to clinical observations and theoretical assertions, such as the premature use of clinical interpretations, with the assumption that more confidence in such therapeutic guidelines can be gained when they are supported by multiple knowledge sources (empirical, clinical, conceptual). Finally, training implications related to the monitoring of harmful effects in terms of treatment outcome and process are demarcated.

It is important to define precisely what is and is not meant by "empirically supported treatments,"rigorously based on what is actually known about the nature of experimental therapy research. The criteria for empirically supported treatments merely allow conclusions about whether treatments cause any change beyond the causative effect of such factors as placebo or the passage of time.Applied implications are limited, due to external validity and to the fact that applied decisions are influenced by cost-benefit analyses. Creating increasingly effective therapies through between-group designs is best done by controlled trials specifically aimed at basic questions about the nature of psychological problems and the nature of therapeutic change mechanisms. Naturalistic research is important for external validity but is valuable only if it uses scientifically valid methods to address basic knowledge questions.We love scientific research. There is a type of precisian and beauty that is not present in other ways of acquiring knowledge. Empirical relationships discovered from carefully conducted experimental studies stand as relative truths that show us how things are interrelated at a concrete level and how theories are in need of revision at the conceptual level. In both ways, they provide us with opportunities to perceive and behave in our worlds in increasingly accurate and adaptive ways.When we engage in the scientific enterprise, we agree to follow the same rules of evidence so that we or anyone else who knows these rules can agree on the knowledge so obtained. Of course, there remain numerous areas of potential debate in interpreting the results of any experimental investigation, how they comment on theory revision, and in what ways their demonstrated relationships apply to things beyond the specific questions and circumstances of the investigation. But because we agree in general on issues of measurement, design, methodology, statistics, and how these features affect what we can and cannot conclude, sufficient accord exists to allow confident and continuous progression of increasingly accurate knowledge from which increasingly useful applications can emerge. The history of psychological research (both basic research and therapy outcome research) on which the Task Force on Promotion and Dissemination of Psychological Procedures (1995) report and its updating article (Chambless et al., 1996) owe their foundation is a testimony to this.When the results of scientific studies are applied to new and important questions that may directly or indirectly affect clinical training, clinical treatment, and financial decisions about how to treat, it is useful for us to return to our roots in empirical