A 3-phase model of psychotherapy outcome is proposed that entails progressive improvement of subjectively experienced well-being, reduction in symptomatology, and enhancement of life functioning. The model also predicts that movement into a later phase of treatment depends on whether progress has been made in an earlier phase. Thus, clinical improvement in subjective well-being potentiates symptomatic improvement, and clinical reduction in symptomatic distress potentiates life-functioning improvement. A large sample of psychotherapy patients provided self-reports of subjective well-being, symptomatic distress, and life functioning before beginning individual psychotherapy and after Sessions 2, 4, and 17 when possible. Changes in well-being, symptomatic distress, and life functioning means over this period were consistent with the 3-phase model. Measures of patient status on these 3 variables were converted into dichotomous improvement-nonimprovement scores between intake and each of Sessions 2, 4, and 17. An analysis of 2 x 2 cross-classification tables generated from these dichotomous measures suggested that improvement in well-being precedes and is a probabilistically necessary condition for reduction in symptomatic distress and that symptomatic improvement precedes and is a probabilistically necessary condition for improvement in life functioning.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.

The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy. The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning. The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient. With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patient's ETR to support decisions that would enhance the quality of a clinical service while it is being delivered.

How can we design relevant psychotherapy research? The answer must be shaped by the objectives and potential consumers of such research. For over 40 years, “does psychotherapy work?” (Eysenck, 1952) held the attention of psychotherapy researchers, and randomised clinical trial methodology seemed the most appropriate empirical option for answering this question. There are now well over 500 studies that attest to the efficacy of psychotherapy (see Smith et al, 1980; Shapiro & Shapiro, 1982; Lipsey & Wilson, 1993, for meta-analytic research summaries); it seems that psychotherapy is one of the best documented medical interventions in history. But the conclusion that psychotherapy “works” is akin to finding that antibiotics “work”. We are left with the daunting task of determining which of the wide variety of treatments (psychotherapies, antibiotics) are appropriate for which variety of illnesses (psychopathologies, infections). Morris Parloff (1982) warned us of this need for specificity in his classic article, “Bambi meets Godzilla”, but our preoccupation with documenting the efficacy of psychotherapy has only recently abated enough to mount empirical studies of such specificity.

No abstract

Patterns of change in mental health were identified for 118 recently widowed participants using the Integra Outpatient Tracking Assessment, Mental Health Index. Change was measured 4 times over the first 2 years of bereavement using a cohort sequential design. It was hypothesized that application of the psychotherapy phase model would have some use in understanding the various ways in which people grieve. The overall pattern of change in mental health was similar to that of the psychotherapy dosage and psychotherapy phase models and indicated a dramatic change in overall mental health, well-being, and symptoms during the beginning phases of bereavement followed by a plateau. At 24 months after the death, participants had not attained the same level of mental health as the general population. Within limitations of the design and sample, 2 conclusions were reached: (a) the overall pattern of change in bereavement was similar to that of distressed patients receiving outpatient mental health services, and (b) the patterns of change for individuals vary, making it important to consider clinical characteristics that might account for individual differences. These findings help establish an empirical model of grief that has use for clinical interventions.

The purpose of this study was to identify empirically patterns of grief among 141 older bereaved spouses. A longitudinal hierarchical cluster procedure with the Ward agglomeration method was used to identify distinct clusters based on grief scores. Three clusters were identified: common (49%), resilient (34%), and chronic (17%) grief. Members of the common grief cluster experienced elevated levels of grief and depressive symptoms that decreased over time. Members of the resilient cluster experienced the lowest levels of grief and depression and the highest quality of life. The chronic grief cluster experienced the highest levels of grief and depression, more sudden deaths, the lowest self-esteem, and the highest marital dependency. The majority in this chronic cluster also met proposed criteria for a diagnosis of complicated grief. Five out of every six bereaved spouses adjusted well over time, and about a third of these showed considerable resilience without negative consequences. One out of six experienced a chronic grief syndrome. Early identification of this syndrome can lead to referral to newly emergent treatments specific for grief.

The information processing demands of planning and conducting psychotherapy and the types of information that clinicians value potentially can inform research that is likely to be useful to clinicians. Four approaches to conducting research on psychotherapy issues-technology transfer studies, quasi-experimental single-case designs, mental health services research, and case-focused patient profiling-have the potential to inform the practicing therapist. These approaches generally are either treatment focused or patient focused, and can vary in their relevance to the individual case.