Psychotherapy: Theory, Research, Practice, Training Copyright 2006 by the American Psychological Association 2006, Vol. 43, No. 2, 216–231 0033-3204/06/$12.00 DOI: 10.1037/0033-3204.43.2.216 BEYOND BRAND NAMES OF PSYCHOTHERAPY: IDENTIFYING EMPIRICALLY SUPPORTED CHANGE PROCESSES J. STUART ABLON AND TAI KATZENSTEIN RAYMOND A. LEVY University of California at Berkeley Massachusetts General Hospital and Harvard Medical School There is considerable debate about characterized the treatments: Adher- which empirical research methods best ence to cognitive–behavioral process advance clinical outcomes in psycho- was most characteristic, adherence to therapy. The prevailing tendency has interpersonal and psychodynamic pro- been to test treatment packages using cess, however, was most predictive of randomized, controlled clinical trials. positive outcome. Specific process pre- Recently, focus has shifted to consider- dictors of outcome were identified using ing how studying the process of change the Psychotherapy Process Q-Set. in naturalistic treatments can be a use- These findings demonstrate how process ful complement to controlled trials. Cli- research can be used to empirically nicians self-identifying as psychody- validate change processes in naturalis- namic treated 17 panic disorder tic treatments as opposed to treatment patients in naturalistic psychotherapy packages in controlled trials. for an average of 21 sessions. Patients achieved statistically significant reduc- Keywords: panic disorder, psychother- tions in symptoms across all domains. apy process and outcome, psychody- Rates of remission and clinically signif- namic psychotherapy, change processes icant change as well as effect sizes were commensurate with those of em- pirically supported therapies for panic Much attention has been paid recently to the conflict between those who favor the empirically disorder. Treatment gains were main- supported treatment (EST) movement and those tained at 6-month follow-up. Intensive who are skeptical of this model. It is beyond the analysis of the process of the treat- scope and not the intention of this paper to review ments revealed that integrative elements the specifics of this complicated argument. This study, however, represents an attempt to bridge the gap between these warring factions. As has J. Stuart Ablon, Raymond A. Levy, Psychotherapy Re- been suggested (Ablon & Jones, 2002; Ablon & search Program, Massachusetts General Hospital and Harvard Marci, 2004; Westen, Novotny, & Thompson- Medical School; and Tai Katzenstein, University of California Brenner, 2004) highlighting the significant limi- at Berkeley. tations of controlled clinical trials does not mean We thank the clinicians from the MGH Psychotherapy that empirical research has nothing to offer the Research Program for their willingness to participate in the practice of psychotherapy. Likewise, assuming study and the members of the Berkeley Psychotherapy Re- that empirical methods can contribute to advanc- search Project for their invaluable help with process ratings. Correspondence regarding this article should be addressed ing clinical outcomes does not mean that experi- to J. Stuart Ablon, PhD, Department of Psychiatry, MA Gen- enced practitioners do not know how to practice eral Hospital, 313 Washington Street, Suite 402, Newton, MA effectively. On the contrary, many researchers 02458. E-mail: [email protected] have argued that a focus on empirically validat- 216 Beyond Brand Names of Psychotherapy ing change processes in naturalistic treatment Among these psychosocial interventions, cogni- would be a fruitful complement to controlled tive–behavioral treatments (CBT) have most trials (Garfield, 1998; Goldfried & Wolfe, 1996; consistently demonstrated efficacy using the con- Howard et al., 1996). This study represents one trolled clinical trial paradigm. The success of attempt to shift the focus on prescriptive treat- cognitive–behavioral protocols, such as Panic- ment packages to studying intensively what a Control Therapy (Barlow et al., 1989), in allevi- group of experienced clinicians do when treating ating panic patients’ symptoms is reflected in the patients with shared diagnoses and presenting delineation of CBT interventions as “standard problems. As such, the treatments we studied treatment” by the NIH Consensus Development might be best described as representing “treat- Conference on Panic Disorder. It is important to ment as usual” in the community. Assuming that note, however, that most ESTs such as Panic experienced clinicians might help their patients Control Therapy have not been tested systemati- achieve symptomatic improvement, we used em- cally against legitimate alternative psychosocial pirical methods to identify the change processes treatments or treatment as usual in the commu- present in a naturalistic treatment so that we nity. Rather, in controlled trials in the laboratory, could learn how and why patients improved. If treatments are usually tested against medication, empirically validated change processes could be wait list controls, psychoeducation, or some ver- identified, we would have an empirical basis from sion of purely supportive intervention. Therefore, which to develop or amend clinically relevant clinicians are often unsure as to the true efficacy treatments. of such approaches relative to other forms of Our previous research (see Ablon & Jones, treatment. In addition, ESTs for diverse clients 1998, 2002) has demonstrated the dangers of with panic disorder have yet to be identified. drawing conclusions about why a treatment is Why do clinicians continue to practice, and effective without studying process correlates of why should we explore the potential utility of outcome. Even under tightly controlled condi- exploratory (as opposed to prescriptive) psycho- tions, treatments often share significant elements therapy for panic disorder given the high efficacy of process borrowed from other theoretical ap- rates of cognitive–behavioral treatment (CBT)? proaches. Interestingly, these borrowed elements Though CBT interventions have proven highly can be the ingredients that predict positive out- comes for patients. In this study, we asked clini- effective for many individuals, this approach is cians who self-identified as psychodynamic in not effective for all patients (Craske & Barlow, their primary theoretical orientation to treat a 2001; Milrod et al., 2001). In closely controlled group of patients with panic disorder as they trials, investigators have reported as many as normally would in their clinical practices while 38% of patients remain symptomatic (Milrod et we studied the process and outcome of the treat- al., 2001) or relapse subsequent to treatment dis- ments. We chose psychodynamic therapists and continuation (Milrod & Busch, 1996). Exposure- panic disorder patients because psychodynami- based interventions that work well for some pa- cally oriented clinicians frequently treat patients tients can be prohibitively overwhelming for with panic disorder despite the fact that psy- others. Some patients also fail to or refuse to chodynamic psychotherapy is not an EST for comply with the directive approaches and out-of- panic disorder and ESTs do exist for this popu- session work constituting the cornerstone of lation (e.g., Panic Control Therapy, see Barlow et many cognitive–behavioral treatments (Milrod et al., 1989) that have been well tested in the labo- al., 2001). For other patients, the idea of a treat- ratory. We briefly describe the background of ment that is not based on the exploration of psychotherapeutic treatment of panic disorder be- the personal meaning of symptoms is intellectu- low before detailing the methods used. ally unsatisfying to the point that they reject the Because of the tremendous and incontrovert- treatment. Clearly, for certain panic patients symp- ible psychological, emotional, and social costs of toms persist despite treatment with cognitive– living with panic disorder (Markowitz, Weiss- behavioral interventions. Nonprescriptive psy- man, & Ouellette, 1989; Swenson, Cox, & chotherapeutic approaches are needed to meet the Woszezy, 1992) much effort has been dedicated treatment demands of the subset of panic patients to developing and implementing effective psy- who do not respond to prescriptive approaches or chotherapeutic interventions for panic disorder. elect to pursue exploratory treatments. 217 Ablon, Levy, and Katzenstein Problematically, to date in the literature there clinicians practicing psychotherapies that have has been little systematic investigation of nonpre- not been thoroughly evaluated empirically. Fur- scriptive treatments. There is support for the ef- thermore, empirical studies examining change fectiveness of brief psychodynamic treatments in processes in nonprescriptive treatments for panic the form of qualitative case studies and theoreti- disorder do not exist to our knowledge. It is cal papers (Abend, 1989; Gabbard, 1990; Milrod likely, however, that process predictors common & Busch, 1996; Milrod & Shear, 1991; Sifneos, to many therapies, such as the degree of thera- 1972). Studies examining the effectiveness of peutic alliance fostered, are likely predictors of supportive, nondirective, and nonbehavioral outcome in psychotherapy of panic disorder as treatments for panic disorder (D. F. Klein, Zitrin, well (e.g., Crits-Christoph and Gibbons, 2003). Woerner, & Ross, 1983; Shear, Pilkonis, Cloitre, The aims of this study are to (1) examine the & Leon, 1994) offer further