Disentangling Trait-Like Between-Individual vs. State-Like Within-Individual Effects in Studying the Mechanisms of Change in CBT

Abstract

Hofmann et al. argued that “[w]hile the clinical field has produced a dizzying number of treatment models and treatment protocols for virtually every psychiatric and psychological problem imaginable, increases in understanding of the processes of change in psychotherapy has been slow to arrive.” We propose that one of the reasons for the slow progress is that prior psychotherapy research conflates trait-like and state-like components of mechanisms of change. Trait-like components can serve as prescriptive or prognostic variables, whereas state-like components reflect within-client processes of change, and may highlight active ingredients of successful treatment. Distinguishing between the two is essential for clarifying the underlying processes of change in psychotherapy, and ultimately identifying empirically-derived individualized treatment targets. We review studies that implement methodological and statistical approaches for disentangling the two. These studies clarified particular mechanisms of change that may operate in a given treatment, highlighted differences in the processes of change between different treatments, and explored the within-individual interplay between different mechanisms of change during treatment. Examples include studies investigating the therapeutic role of behavioral, cognitive, and interpersonal skills, as well as emotional processing. We conclude with suggestions for future research, including attention to diversity, improved measurement to facilitate a reliable and valid estimation of trait-like and state-like components, the use of appropriate statistical approaches to adequately disentangle the two components, integration of theory-driven and data-driven methods of analysis, and the need to experimentally manipulate the state-like changes in a given mechanism of change to strengthen causal inferences.

A strong alliance is not enough: Item-level variation in an alliance measure moderates the alliance strength and client outcome relationship.

“…Most previous research investigating the effect of WA on client functioning has focused on nomothetic variations and have examined differences in WA or functioning levels between or across clients (Flückiger et al, 2018). However, we agree with Zilcha-Mano & Webb’s (2021) argument that intraindividual variations are crucial to explore because they reflect therapeutic changes within clients. Therefore, we explored the within-client effects of alliance strength (WAI-M) and alliance WAI-IIV on client functioning.…”

Changes in client attachment in relation to client distress: A response surface analysis.

“…Attachment theory focuses on idiographic, state-like components of client attachment, stating that when a client’s attachment insecurity improves, the client experiences less psychological distress. Because the state-like processes reflect therapeutic changes within clients, the idiographic, state-like intraindividual variations in client attachment are crucial to be explored, rather than nomothetic, trait-like interpersonal variations (Zilcha-Mano & Webb, 2021; Beltz et al, 2016). However, previous research examining client attachment has focused on nomothetic variations, examining differences in attachment between or across clients (Beltz et al, 2016).…”

Connecting over the internet: Establishing the therapeutic alliance in an internet-based treatment for depressed adolescents

“…These include the client’s expectations of therapy, attachment, trauma history, interpersonal functioning, symptom severity, and personality (Elvins & Green, 2008; Levin et al, 2012). Recently, research into mechanisms of change in psychotherapy has highlighted the need to distinguish between trait-like (between-individuals variance) and state-like (within-individual variance) components (Zilcha-Mano & Webb, 2021; Zilcha-Mano et al, 2018). Regarding therapeutic alliance, it may be important to disentangle individuals’ baseline trait-like factors - such as attachment security or interpersonal style - from genuine changes in state-like components that influence therapeutic alliance over the course of therapy.…”

“…Relatedly, the data seemed to suggest that some young people are ‘ready’ to form a therapeutic alliance from the start of therapy, whereas others may take more time, even when their TSW uses the same techniques. An important question for future research will be to see if it is possible to identify differences in pre-treatment trait-like components that characterise these two groups of participants, and to distinguish these from state-like components that reflect within-client processes of change over the course of therapy, and which may contribute to growth in therapeutic alliance over time (Zilcha-Mano & Webb, 2021; Zilcha-Mano et al, 2018). In this regard, there is some indication that epistemic trust might be a fruitful avenue of research.…”